Aquatic Exercise for Pregnancy

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Aquatic Exercise for Pregnancy

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Written by two specialist coaches for the Register of Exercise Professionals (UK), who have developed the UK’s first level 3 Pregnancy Aquatics, Nutrition and Health module at the University of Salford, this book is the culmination of over ten years’ passionate interest and work in the field of aquanatal exercise.

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Water generally – aquanatal specifically The anatomy of movement and the main muscles Pool safety – risk assessment and management Getting the best out of your classes Aquanatal choreography Practical tips for more fun and interesting classes Contraindicated aquanatal exercises The pelvic floor and aquanatal exercise Ethical considerations Public health, physical activity and aquanatal exercise Aquanatal exercise and parent education Nutrition during pregnancy and for physical exercise The law and aquanatal exercise Voice care for the aquanatal exercise coach Marketing within the NHS Sample screening and risk assessment forms Sample sessions plans and client information sheets

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Susan Baines and Susie Murphy

PUBLISHING

AQUATIC EXERCISE FOR PREGNANCY

Aimed at midwives and health and fitness professionals, this practical, illustrated resource book covers every aspect of one of the most beneficial forms of exercise for pregnant mothers. Aquanatal exercise combines the therapeutic properties of warm water with suitably chosen music, to create a unique method of exercising. Unlike dry land exercise, which tends to work specific parts of the body, aquanatal exercise gently works the whole body.

Contents include:

Aquatic Exercise for pregnancy

a resource book for midwives and health and fitness professionals


PUBLISHING

M&K Aquanatal prelims:Aquarobics designs 14/05/2010 16:54 Page i

Aquatic Exercise for Pregnancy

M&K Aquanatal prelims:Aquarobics designs 14/05/2010 16:54 Page ii

Other health & social care books from M&K include: Fat Matters: From sociology to science ISBN: 978-1-905539-39-0 · 2010 Research Issues in Health and Social Care ISBN: 978-1-905539-20-8 · 2009 Identification and Treatment of Alcohol Dependency ISBN: 978-1-905539-16-1 · 2008 Nutrition for Children: A no nonsense guide for parents ISBN: 978-1-905539-26-0 · 2008 Inter-professional Approaches to Young Fathers ISBN: 978-1-905539-29-1 · 2008 Pre-Teen and Teenage Pregnancy: A twenty-first century reality ISBN: 978-1-905539-11-6 · 2007

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Aquatic Exercise for Pregnancy a resource book for midwives and health and fitness professionals


M&K Aquanatal prelims:Aquarobics designs 14/05/2010 16:54 Page iv

Aquatic Exercise for Pregnancy Susan Baines, Susie Murphy ISBN: 978-1-905539-42-0 First published 2010 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior permission of the publishers or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London, W1T 4LP. Permissions may be sought directly from M&K Publishing, phone: 01768 773030, fax: 01768 781099 or email: [email protected] Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Notice Clinical practice and medical knowledge constantly evolve. Standard safety precautions must be followed, but, as knowledge is broadened by research, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers must check the most current product information provided by the manufacturer of each drug to be administered and verify the dosages and correct administration, as well as contraindications. It is the responsibility of the practitioner, utilising the experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Any brands mentioned in this book are as examples only and are not endorsed by the publisher. Neither the publisher nor the authors assume any liability for any injury and/or damage to persons or property arising from this publication.

The Publisher To contact M&K Publishing write to: M&K Update Ltd · The Old Bakery · St. John's Street Keswick · Cumbria CA12 5AS Tel: 01768 773030 · Fax: 01768 781099 [email protected] www.mkupdate.co.uk Designed & typeset by Mary Blood Illustrated by Mary Blood and Fliss Watts Printed in England by Reed’s Printers, Penrith.

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Contents List of figures vi Acknowledgements vii Introduction ix Part 1 Aquanatal exercise Chapter 1 Water generally – aquanatal specifically 3 Chapter 2 The anatomy of movement 11 Chapter 3 Pool safety – risk assessment and management 17 Chapter 4 Getting the best out of your classes 23 Chapter 5 Aquanatal choreography 31 Chapter 6 Practical tips for more fun and interesting classes 41 Chapter 7 Contra-indicated aquanatal exercises 45 Chapter 8 The pelvic floor and aquanatal exercise 47 Part 2 Aquanatal exercise – the wider context Chapter 9 Ethical considerations 57 Chapter 10 Public health, physical activity and aquanatal exercise 63 Chapter 11 Aquanatal exercise and parent education 71 Chapter 12 Nutrition during pregnancy and for physical exercise 77 Chapter 13 The law and aquanatal exercise 83 Chapter 14 Voice care for the aquanatal exercise coach 87 Chapter 15 Marketing within the NHS 91 Part 3 Developing your practice Useful sources of information and contacts 101 Appendices 1 Main muscles of the body that you need to know 105 2 Aquanatal exercise participant screening form 106 3 Client information sheet 107 4 Sample risk assessment pro-forma 108 5 Blank session plan – aims of whole session 109 6 An example of a legal case study 110 7 Continuing professional development – observation of a pregnancy aquatic session 111 8 Aquanatal session plans 114 Index 121

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List of figures Chapter 1

Figure 1.1 Oscillating water molecule 4 Figure 1.2 Diagram of hand positions (cup/scoop, slice, punch, lift, push away) 6

Chapter 2

Figure 2.1 The anatomical position (anterior aspect) 11 Figure 2.2 Body planes 12 Figure 2.3 ‘Q’ pump exercise 13 Figure 2.4 Biceps curl 15 Figure 2.5 Extension of elbow 15

Chapter 4

Figure 4.1 Coach in warm up mode 24 Figure 4.2 ‘Sea horse’ woggle position 26 Figure 4.3 Group circle relaxation 27 Figure 4.4 Professional coach 28

Chapter 5

Figure 5.1 ‘Cutting a diamond’ 33 Figure 5.2 Sweeping arms 34 Figure 5.3 Hip circles 34

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Chapter 6

Figure 6.1 ‘The waiter’ 42

Chapter 8

Figure 8.1 Side view of pelvic anatomy 47

Chapter 11

Figure 11.1 Upright birthing position 74

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Acknowledgements We would like to express our love and gratitude to Michael and Peter, our long-suffering but patient husbands, for their care of us and their support whilst we wrote this book.

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Introduction This book is the culmination of over a decade’s worth of interest in aquanatal exercise. Our journey into all things aquatic has had its fair share of ups and downs since we embarked upon it in the summer of 1997. I, for my part, had been managing a maternity and women’s health project in Bolton, Lancashire and was looking at possible strategies to support maternal and fetal health during the antenatal period and Susie was simply doing what Susie does best, with her unquenchable enthusiasm for a new challenge! We met, qualified as professional registrants of the now defunct UK Fitness Register and the rest, as they say, is history. But from the very beginning we said that one day we would write a book, one designed to be used and not just added to one’s book shelf, in need of occasional dusting and only to be opened in times of specific need. We wanted to compile a living book, which would get bent at the edges from being stuffed into a gym bag, get defaced (from all the notes scribbled on its pages) and like a faithful old dog, get rather wet at times from being too close to the water. Our book is for using. It is for offering help and support to our caring and compassionate midwifery colleagues throughout the UK and across the world, who like us share a passion for facilitating aquanatal exercise. We are both now specialist Level 3 coaches for the Register of Exercise Professionals (UK), have won a Vice Chancellor’s research award at the University of Salford, have developed the UK’s first academically underpinned level 3 Pregnancy Aquatics, Nutrition and Health module at the University of Salford and have had the opportunity to travel to Australia to spread the word about pregnancy aquatic exercise. We still live, breathe and sleep aquanatal and are so convinced of the wonderful health benefits of this activity for mothers that we feel like shouting from the rooftops! Surely, if its benefits could be bottled, then we feel women would be tipsy with health. It is perhaps strange to some, but certainly not to Susie and me, that those midwives who like us become interested in aquanatal exercise, also become passionate about it… We hope you enjoy “your” book! Love to you all Sue and Susie 2010

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Part 1

Aquanatal exercise



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Chapter 1 Water generally – aquanatal specifically “Be praised, my lord, through sister water; she is very useful and humble and precious and pure” From The Canticle of the Sun by Saint Francis of Assisi (1181–1226) (Circa 1225) (www.wikiquote.org)

"Everyone understands that water is essential to life. But many are only just now beginning to grasp how essential it is to everything in life – food, energy, transportation, nature, leisure, identity, culture, social norms, and virtually all the products used on a daily basis” (World Business Council for Sustainable Development) (WBCSD 2006)

Throughout history, there is a strong human affinity with this natural medium. Theologian, Bernard Frank, offers: “You could write the story of man’s growth in terms of his epic concerns with water” (www.cyber-nook.com/water/p-quotes.htm)

The well known underwater explorer, Jacques Cousteau (1910–1997) observed that, “from birth, man carries the weight of gravity on his shoulders. He is bolted to earth. But man has only to sink beneath the surface and he is free” (Time magazine 28 March, 1960) (www.wikiquote.org)

Pregnancy aquatics – aquanatal exercise What is aquanatal exercise? It is a term coined from “aquarobics” which according to Baum (2000, p 5) refers to “a system of exercises to music performed in the water”. Whilst aquarobics refers generally to any social group, aquanatal is more specific and refers to just one, that of pregnant women. It has therefore been afforded “specialist” status within the UK Register of Exercise Professionals (REP), the professional regulatory body that identifies and maintains coaching standards across the UK. The REP demands a high level of expertise and competency from all of the coaches listed on its register, but nowhere is this more evident than on that part of the register open to aquanatal coaches. Mainly, due to the nature of pregnancy exercise, this requires special consideration to be afforded to two persons, the mother and her unborn baby. Aquanatal exercise combines the therapeutic properties of warm water with suitably chosen music, to create a unique medium for exercising the body. But unlike dry land exercise, which tends to work various parts of the body specifically, aquanatal exercise works the whole body and can therefore be considered as holistic.


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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals There are therefore very real benefits from exercising in water during pregnancy, which the pregnant woman would simply not experience from engaging in dry land aerobic activity. For example, as the exercises work all the major joints and muscle groups, there is little likelihood of overworking a particular one and causing joint and muscular strain. Also, there is far less likelihood of creating maternal fatigue, a common problem during pregnancy, as the sessions are specifically designed to take account of women’s changing physiology so as to maximise safety for both mother and baby. We shall be considering all the components of planning an effective aquanatal class in a later chapter, but for now we wish to look a little more closely at why we personally feel, as experienced aquanatal coaches, that women generally associate so well with an aquatic environment. Over the last twelve years of providing aquanatal exercise classes, we have strived to make sense of both our feelings about and our observations of women in the water. Whilst acknowledging the human affinity to water, we cannot actually explain why women seem to gain so much from this type of environment. Nevertheless, women seem entirely comfortable and happy in a pool of deliciously warm water. (See Further reading for this chapter; Elaine Morgan’s theories are interesting on this point.)

The properties of water Water is the only element that can exist in three very different forms: liquid (water), solid (ice) and gas (steam); and therefore its structure when a liquid is very different from when it becomes a solid. Obviously as aquatic exercise professionals, we need to focus on water when in its liquid form so that we can appraise its properties and therefore understand why it is such a positive medium for mothers to exercise in and how it enhances physical fitness and well being. Water’s molecular make up can be described as a combination of three atoms: two of hydrogen and one of oxygen (Chaplin 2007). The overall molecular shape is not completely circular as perhaps might be expected, but it takes the shape of a V which maintains the molecules in a state of flux, ready for action. This unique composition, according to Graham and Sterry (2000), allows for the substance to take part in a simple chemical reaction; the molecules’ ability to form clusters and become sticky when something impacts on their mobility. So when an object breaks the surface of the water and becomes immersed, the molecules attach themselves to it. Consider yourself when immersed in a bath of water and take a moment to reflect on how the water is behaving on and around your body. Does the water not seem to feel like a film on the skin and also to exert a feeling of light pleasurable compression to the parts submerged within it? These feelings help to formulate a basic understanding of why it is an ideal medium to exercise in, as it demonstrates both protective and supportive qualities whilst exerting pressure (drag) on the body and therefore muscular resistance. It is almost as if an invisible force is attached to the body, explaining why aquatic exercise is not only powerful and efficient but also why these properties can be utilised to make it fun.

Figure 1.1 Oscillating water molecule (courtesy Martin Chaplin, London South Bank University)

Considering the individual properties of water, there are three types of resistance: viscous resistance, frontal resistance and eddy resistance (drag).


Water generally – aquanatal specifically

Viscosity – viscous resistance Viscosity refers to the friction between molecules of a liquid (or gas) causing them to adhere to each other (AEA 2006). This is termed cohesion and when applied to a submerged body in liquid water, adhesion. Water is thicker and therefore more viscous than air so it adheres to the body and a resistance to motion is created. Galileo found that a body falls more slowly through water than if it fell through air, so if this principle is applied to a body exercising in water, it can be seen that the size of the body and the speed it is moving, can affect the resistance to the movement caused by the viscosity (drag) of the water. The larger the surface area’ the more difficult movement is in the water. Individual body shape and the size of the woman and working either individually or in a large group setting will therefore create more or less resistance. This is essential knowledge when planning an aquanatal session, as the exercises need to be varied in order to effectively create and thus manage the degree of resistance provided in a session in order to ensure the woman does not become exhausted and thus at risk of injury. Resistance requires greater muscular effort and energy consumption, so making exercise in water much more effective if carefully considered. It needs to be recognised that viscous resistance can be altered in the water to suit the needs of the individual woman. One such strategy might be to work more moderately in a streamlined way. This is a smoother way of moving through the water, more continuous, steady and linear, which requires far less physical effort. Alternatively, to increase intensity, movement can be more turbulent in that it requires more irregular directional changes. Eddy drag is created, which will be considered separately later on in this chapter. Viscosity is also affected by water temperature and the surrounding ambient temperature. The colder the water the more viscous it will be and the harder it will be for mothers to work in. This is one reason why it is absolutely essential to record the water temperature prior to the class entering the pool, as cold water can result in maternal injury. Water temperature will be considered later, along with heat regulation.

Frontal resistance When a body is immersed in water, its every movement is subject to a force twelve times more resistant than air. The body therefore needs to work approximately three times harder than when exercising on dry land (Lawrence 2004). By understanding this, exercise coaches can utilise this force positively to achieve muscle overload, whereby the cardiovascular system and the muscular systems of the body can generate more muscle fibres and therefore develop over time to their maximum level of efficiency. Additional use of aquatic resistors such as weighted aids can further enhance this effect. Frontal resistance is generally considered in the aerobic and muscular strength components of an aquanatal programme; for example, in the former, when working a little more quickly and making whole group directional turns, side stepping with the torso facing forwards and making small quarterdegree turns and in the latter, when using resistor aids to increase muscular strength and endurance. It needs to be noted that movement in the water is generally performed at half the speed of similar dry land activity and so care needs to be taken when simply asking mothers to move more quickly in the water. Pools are slippery places and there is the potential to cause injury. Also, speed on its own will not equate to increased exercise efficiency as there might be an associated reduction in the range of movements used. There is a need therefore to increase the range of movements by considering the levers (limbs) of the body. By changing from a short (flexed) arm to a long (extended) arm, for example, the frontal surface area of the body will be increased and therefore more effort and energy will be needed. Hand position is also a useful tool; by changing the hands from a slicing action (which is more streamlined) to a cupped position, more surface area will be created and therefore more energy will be needed.

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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals There are generally five hand positions to be considered: 1. Cup/scoop (palm down with fingers curled to paddle the water from front to back and side to side) 2. Slice (hand vertical slicing through the water) 3. Punch (fist to punch the water – effort) 4. Lift (palm uppermost to waft the water) 5. Push (palms vertical whilst moving forward to create direct frontal resistance) Additionally, aids can be held to create resistance.

Figure 1. 2 Diagram of hand positions (clockwise from top: cup/scoop, slice, punch, lift, push away)

Eddy resistance (drag) By moving forward in the water in a turbulent way, eddy currents are formed. Also, when a number of bodies are moving more speedily in the water, the eddy resistance is increased. Eddy currents restrict directional change and make bodily movements more difficult, so balance, posture and core stability need to be considered to avoid injury. Swirls of water are forced into the spaces left by the movement and this creates a dragging force and therefore a resistance to changing direction. It is useful therefore to only include travel in an aquanatal session if mothers are generally fit; otherwise omit or consider alternating travel with periods of static activity. Multi-directional travel is only utilised in the aerobic component, however, when the body has warmed up sufficiently and become acclimatised to working in the water environment.

Slipstream This term refers to a current of water being driven backwards by a body moving forwards in the water. The body breaks the surface tension, forcing the water to be displaced in its wake to the rear and the side of the body by the creation of waves or bubbles. This is useful to know about, as a less able woman should be advised to position herself a little more closely to the more able woman moving in front of her, in order


Water generally – aquanatal specifically to work with a little less effort within the slipstream she is creating. Ducks are a wonderful example of moving in a slipstream to force water out of the way.

Surface tension This refers to the surface molecules of a fluid and how they are arranged so that they appear to stick together and so form a skin. The surface area is therefore tense and forms a demarcation between the air and the water. Care needs to be taken to ensure the class exercise their limbs either fully submerged in the water or outside it in the air, as by constantly needing to break though the water’s surface tension with ballistic or projectile movements, they will incur the risk of twisting their joints. Visualise that you are just about to enter the pool and there is no one else in the water. The water appears to be completely still until you disturb it by breaking through the top layer in order to enter it. You have broken through the surface tension. Now reflect on how it sometimes feels when attempting to leave the pool. Is it sometimes difficult? Do you need to almost lever yourself out of the water at times? This is due to the surface tension creating an interaction between the water and the air and the water being heavier, exerting pressure to pull the body back into it. It is useful to be aware of this, as some women may experience difficulty when leaving the pool due to their developing pregnancy culminating in a larger frontal surface area and thus more weight trying to break through the surface tension of the water. A good aquanatal coach will always keep a watchful eye at this time and offer help as necessary.

Buoyancy Buoyancy is the opposing force to gravity. When on dry land we are said to be grounded, as gravity pushes the body in a downward direction, whereas when in water, we can float, as buoyancy pushes the body upwards. Archimedes, the ancient Greek scholar, can be credited with discovering why a body or object floats. He was sitting in the public baths (circa 287 AD) when he observed that the level of the water rose in the bath as he stepped into it. He went on to calculate the mathematics of buoyancy and water displacement. This famous “eureka” moment allowed him to understand that the weight of an immersed object is relative to the amount of water it displaces and that because the weight is calculated in air, with gravity pushing it down, the weight of the object will become less in water, due to the buoyancy pushing it up. Therefore if an object or body is less dense than water, its weight will decrease to zero before it can be fully submerged and therefore when it has displaced the same amount of water as its own weight, it will float. This is generally referred to as its centre of buoyancy. This principle applies to any object immersed in any fluid, but the denser the fluid the more buoyant is an object within it. An obvious example of this is the Dead Sea, where the high salt concentration easily allows partially submerged objects to float. A body is more buoyant in deeper water, which explains the fact that scuba divers need to be weighted down when deep diving. In an aquanatal class, women are ideally submerged to the level of their xiphisternum and when positioning their feet on the floor, do not experience weightlessness. They do however, experience less impact on their lower limbs and are more able to move freely in the water as their bodies feel lighter. This is valuable during pregnancy, when mobility on dry land may be restricted due to oedema, poor circulation, back or joint pain, weight gain and general joint instability due to the effects of relaxin and progesterone. Consider for a moment a mother who has been diagnosed with symphysis pubis dysfunction (SPD). She is rendered almost physically disabled when attempting to mobilise on dry land, but experiences not only a wider range of easier movements when in the water environment, but also freedom from pressure pain due to the buoyancy. It is reported that the incidence of SPD varies between 1–36 and 1–300 of the British population (Owens, Pearson and Mason 2002) and this may be a conservative estimate, so understandably physiotherapists and doctors are recommending that pregnant women engage in this

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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals form of physical activity The relief experienced, albeit temporary, is nonetheless of great value. Another benefit of buoyancy relates to squatting. On dry land this can be quite dangerous to anyone, as the human tendo-Achilles gets shorter if it has not been regularly used throughout daily life and this is true whether the heel does or does not come into contact with a surface. Knee problems, especially chondromalacia patellae (frontal knee pain) can result. Squatting needs therefore to be practised and can be done efficiently and safely in the water, as very little weight passes through the knee joint due to the effects of buoyancy (Koury 1996). Post-exercise soreness is also unusual following an aquanatal exercise session. This is due to the buoyancy rendering all muscle work concentric (shortening) and it is only when working in eccentric mode (lengthening) that fibres can be stretched and damaged, thus resulting in pain. The effects of buoyancy can be used in several ways by the coach when facilitating an aquanatal exercise session and this will be further explained when considering support, assistance, resistance and progression during the aquanatal workout in Chapters 4–6.

Hydrostatic pressure This is often described as molecular water pressure exerted on all surfaces of a body immersed in it. It is very dependent on the depth of water the body is submerged in. For example, a scuba diver will experience it more intensely the deeper he or she dives. Whilst it can be dangerous if not managed carefully in these circumstances, it is quite therapeutic during an aquanatal exercise session, as the mother is only partially submerged in shallower water. The effects of hydrostatic pressure can positively affect the cardiovascular system and help with re-distributing extra cellular fluid back into the systemic circulation (up to 700ml in some cases within an aquanatal session) and thus help to reduce lower limb oedema and increase respiratory efficiency (Hall, Bisson and O’Hare 1990, in Baum 1998). Care needs to be taken however, if a mother has a respiratory condition such as asthma, as she might experience chest tightening, become anxious and have difficulty breathing.

Basic body types Mesomorphs – more muscular with broader shoulders and therefore athletic in appearance Ectomorphs – less muscle and fat; therefore taller and leaner in appearance Endomorphs – high percentage of body fat (also includes those women in advanced pregnancy), tend to be rounder in appearance. Knowledge of these body types is essential to an aquanatal coach, as she will find her sessions include many different individuals with differing abilities in the water. One particular aquatic exercise might appeal to some in the group and be practised effectively, whilst not with others, who might as a consequence find they struggle and could incur personal injury. One example might be performing an exercise which requires the ability to float on the pool surface. When planning an aquanatal exercise session therefore, a good coach will visually assess her mothers and include a wide range of different exercises designed to meet the physical needs of everyone in the group. Just as the midwife teacher would assess the learning styles of the student group in order to assess how they would best learn (Honey & Mumford 1992), she would include a variety of different teaching strategies within her taught session to ensure that everyone learns what is required. In doing this, motivation is strengthened and mothers will return again and again. This highlights the importance of visual screening and effective planning for each aquanatal exercise session.


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Water generally – aquanatal specifically

To summarise ● Aquanatal exercise utilises the beneficial properties of water to provide a holistic exercise workout. ● There is a need to plan aquanatal sessions in order for them to meet the needs of the entire group. ● Knowledge of the properties of water is essential if the aquanatal exercise coach is to provide a safe and effective class. ● Buoyancy is one such property and counteracts the grounding effects of gravity experienced in air. ● All muscular work in the water is concentric which affords greater protection to the body.

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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals

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References Aquatic Exercise Association (2006) Aquatic Fitness Professional Manual 5th edition. Florida: AEA. Baum, G. (1998) Aquarobics; The Training Manual. London: Harcourt. Chaplin, M. http://www.lsbu.ac.uk/water/molecule.html (accessed February 2009). Graham, I. & Sterry, P. (2000) Questions & Answers Book of Facts. Leicester: Kibworth Books p 52. Hall, J., Bisson, D. and O’Hare, J. (1990) The physiology of immersion physiotherapy. Physiotherapy 76 (9): 517–521. in Baum, G. (1998) Aquarobics: The Training Manual. London: Harcourt. Honey, P. and Mumford A. (1992) The Manual of Learning Styles. Maidenhead: Peter Honey. Koury, J.M. (1996) Aquatic Therapy Programming. New Hampshire USA: Human Kinetics Publishers. Lawrence, D. (2004) The complete guide to exercise in water 2nd edition. London: A&C Black p8. Owens, K., Pearson, A. and Mason, G. (2002) Symphysis pubis dysfunction – a cause of significant obstetric morbidity. European Journal of Obstetrics, Gynecology and Reproductive Biology 105 143–46. The Register of Exercise Professionals (2008) www.exerciseregister.org (last accessed 20.04.08). World Business Council for Sustainable Development (WBCSD) (2006) Business in the World of Water: water scenarios to 2025. www.wbcsd.org/includes/getTarget.asp?type=DocDet&id=MTK2MzY (last accessed 12.01.10).

Further reading Morgan, E. (1972) The Descent of Woman. Reprinted twice in 2006. London: Souvenir Press. Morgan, E. (1997) The Aquatic Ape Hypothesis. Reprinted in 2006. London: Souvenir Press.

Useful Sources of Information • Human Kinetics – The Aquatic Exercise Toolbox (contains a Windows compatible CD ROM) PO Box 5076 Champaign IL 61825 – 5076 217-351-5076 or [email protected] (last accessed 20.04.08) • www.pelvicpartnerships.org.uk (date accessed 05.09.08) This website is a registered charity and aims to offer help and support to mothers experiencing SPD. They offer a telephone helpline, produce leaflets and hold local regular meetings. • www.waterworkout.com (date accessed 05.09.08) This website stocks a wide variety of flotation and pressure enhancing resources (as well as DVDs and CDs) to help make your classes more enjoyable and effective.


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Chapter 2 The anatomy of movement This chapter aims to illustrate the complexities associated with human movement in a systematic, basic and therefore user friendly way. By doing so, it is hoped that the aquanatal exercise coach will be able to understand how the body moves and what each joint and muscle group is able to do, and how a particular exercise impacts and benefits that joint or muscle group. Knowledge of movement and human motion or human kinetics is therefore fundamental to ensuring safe and effective classes.

The anatomical position The anatomical position defines the body as being erect and neutral (see Fig 2.1). This anatomical starting point enables us to then consider how the body parts change according to the work they need to do. This neutral position can also be termed 0°. Note how the arms are by the sides, the legs together and the feet facing forward. There is no flexion, extension, hyperextension or rotation. Only the palms face forward, which is termed supination.

Movement We use various anatomical terms to describe how the body is able to move. There are seventeen terms in total and care needs to be taken to ensure that the natural movement for that part of the body is considered within a session of aquanatal exercise, as moving the body unnaturally may result in injury. Whilst there is a need to recognise that the body will be accustomed to naturally adopting these movements on a regular daily basis, for some women, their range of movement might be restricted due to past injury or illness. Care therefore needs to be taken to select appropriate exercises that do not exacerbate their condition further. Movement tends to be further described by considering opposing actions. For example we refer to flexion and extension of the arm, meaning that there is a decreasing angle between two bones when the arm is bent at the elbow out of its neutral anatomical position. The angle

Fig 2. 1 The anatomical position (anterior aspect)


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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals is increased between the two bones when it extends, returning to its anatomical position. The same flexion occurs in the foot with planter flexion at the ankle and extension at the foot with ankle dorsiflexion. We refer to hyperextension, whereby the movement continues past the anatomical neutral position, such as moving the head upwards at the neck to look up. Abduction moves a limb away from the body at the midline. An example of this is to raise the leg to the side. The direct opposite of this is adduction, where the limb is returned towards the body’s midline from a side leg raise. We refer to medial rotation and this is where there is rotation of the axis of a long bone towards the midline of the body, an example being to rotate the arm inwards from the shoulder joint. In opposition, lateral rotation is defined as when the axis of the long bone is rotated outward away from the body such as when the arm rotates outward from the shoulder. The term elevation refers to a part of the body moving towards the head, an example being when the shoulders are shrugged upwards. Conversely, when a part of the body is moved towards the feet, for example when pressing down the shoulders, it is termed depression. Pronation refers to the rotational movement of the forearm medially or to the movement of turning the palm downwards or backwards. Supination is the opposite, where the forearm is rotated laterally or the palm turned upwards or forwards. The term inversion refers to the sole of the foot being moved inwardly or medially, eversion refers to the sole of the foot being turned outwardly or laterally. When the shoulder girdle is moved backwards towards the spine it is referred to as retraction and when it moves forward, away from the spine, it is termed protraction. Finally we use the terms tilt and circumduction, the former being movements of the head, scapulae and pelvis forward and backwards or to the right or left and the latter referring to the circular movement of a limb, which can combine flexion, extension, abduction and adduction of, for example, the arms or legs. The normal range of bodily movements is referred to in mathematical terms by stating how many degrees the part can normally be expected to flex, extend, rotate, abduct, adduct, pronate, or supinate (Heyward 2002). Limited movement is referred to in this mathematical way also, by stating for example, “she has only 50% flexion in her wrist” (the normal being 60–80%).

Planes and axes Planes As can be seen (Fig 2.2) there are three different planes which enable bodily movement. These planes use imaginary lines to create the spatial awareness of movement. We thus refer to movement occurring forwards, backwards, upwards and downwards and from side to side. One way of trying to understand this is to imagine that the planes are made from transparent glass which allows clear visualisation of their

Fig 2.2 Body Planes


The anatomy of movement construction. The sagittal plane is vertical and extends from the front of the body to the back, dividing the body into a right and a left side. The frontal (or coronal) plane is also vertical and divides the body into anterior and posterior sections. The horizontal, or transverse, plane divides the body into upper and lower sections from the midline.

Axes Other imaginary lines throughout the body are termed axes. They occur where two planes meet and are positioned at right angles to each other. There is a vertical or longitudinal axis, a sagittal axis and a frontal axis, therefore. It is important that aquanatal exercise coaches understand these planes and axes, as it helps to ensure workouts are balanced, avoiding too many lateral movements for example. However, movement is complex and as one part can be moving in one directional plane, others can be moving in other directional planes, so care needs to be taken that the moves are as controlled as possible. There is, however, evidence to suggest that water enables more multidimensional movement; and more moves in the transverse plane can be achieved in water than on dry land, especially when exercising the legs (Aquatic Exercise Association 2006).

Using this knowledge of movement to plan suitable aquanatal exercises Some examples: Flexion and extension: Upper body – biceps and triceps curls, bending the arms at the elbow both in and out of the water. Vary by alternating the arms in sequence and pressing the arms down and back. Adduction and abduction: Lower body – hip abductors and adductors. Lifting the leg to the side with toes facing forwards and returning it to the centre (avoid too wide a step as can de-stabilise the pubic joint) Rotation: Upper body – shoulder rolls Middle body – waist circles. Do a figure of 8 movement (slowly) similar to belly dancing. There is a need to ensure good posture and continued slow breathing (good for a slow and gentle warm up exercise). Lower body – foot circles (avoid pointing the toes so as to minimise the risk of developing cramp. By keeping the foot straight, more stability can be achieved when only one foot is on the pool floor) Pronation: Hand paddling in the water with the palm turned downwards and backwards Supination: A “Q pump” exercise – rotating the forearms laterally (simultaneously) with both the palms upwards and forwards. Elevation: Upper body – shoulder shrugs Depression: Upper body – shoulder presses downwards Middle body – alternate gentle side bends Lower body – alternate foot to floor (on the spot as a warm up exercise or with movement around the pool as part of the aerobic curve). Fig 2.3 “Q pump” exercise More suggestions are offered in the session plans in the Appendices.

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Bones and joints The human skeleton consists of 206 bones (Wylie 2000) which provide a framework for movement. Bones are basically classified into five shapes: long, short, flat, irregular and sesamoid. A joint is where two bones meet, allowing for alterations to posture and movement. Of the three types of joints, fibrous, cartilaginous and synovial, it is the latter that we as aquanatal instructors are most interested in as they allow for the greatest movement. Their capsule contains synovial fluid which acts as a natural lubricant to aid movement. There are six types of synovial joints in the body: ball and socket, hinge, ellipsoidal, saddle, gliding, and pivot joints. Ball and socket joints allow all types of movement to occur and examples include the hips and shoulders. An example of a hinge joint is the elbow which can both flex and extend. The knees and ankles are forms of modified hinge joints which can also slightly rotate as well. The wrist is an example of an ellipsoidal joint as it can allow all movement except rotation and opposition. Saddle joints include the thumb, which is able to move freely except to rotate. The ankle is a gliding joint and the jaw is both a gliding and hinge joint which can flex, extend and glide. A pivot joint allows rotation around a central axis; for example, the radius and ulna in the forearm can rotate around each other.

Muscle action both in and out of the water There are over 600 muscles in the human body, classified as smooth or involuntary muscle, cardiac muscle and skeletal muscle. It is the latter we as exercise providers are most interested in. These muscles have generally three main functions, to help maintain skeletal posture, to help create movement and to provide heat (Aquatic Exercise Association 2006). Muscles are able to contract (shorten concentrically) and retract (lengthen eccentrically) but the actual work is only achieved when the muscles are working in concentric mode. We therefore refer to muscular activity as concentric and eccentric and interestingly all muscular work is concentric whilst in suitably deep water, immediately highlighting its exercise benefits. Muscles tend to work in pairs, one shortening to create the movement, the other elongating to allow for the movement. Other muscles around the joint also act as stabilisers. It is essential to understand this, as a basic knowledge of muscular action is vital before considering how to work muscles in water (see Main muscles of the body, in Appendices).

Levers You need to have at least a basic understanding of levers, when considering how the body moves. The body consists of a system of levers which enable the bones (or rigid bars) to turn about an axis (a joint); the effort to do this derives from the concentric muscle. The bone can be seen as a resistor (R) The joint as the fulcrum (F) The muscle as the effort (E) R+E +F = movement Whilst the mass of a bone can be a resistor, on dry land the force of resistance can be increased by additionally using training aids such as weights. In water, resistance comes from the fluid drag of the water and from floatation and resistor aids such as woggles. We need to know about levers, as individuals vary in body size and power and it is only by careful client screening that a good aquanatal exercise instructor can select the most appropriate type of resistance with the muscular strength and endurance (MSE) section of her class (Aquatic Exercise Association 2006).


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The anatomy of movement Look at the concentric and eccentric muscle action demonstrated in the bicep curl as the two following images demonstrate.

Figure 2.4 Biceps curl Biceps concentric (contracted) Triceps eccentric (elongated)

The opposite effect happens here as the biceps is stretched (eccentric) and the triceps is contracted (concentric), allowing the movement to occur. As all muscle action in water is concentric, maximum efficiency and muscle overload can be created. Muscle overload is not a negative term, but rather a positive state, whereby the muscle fibres have been worked efficiently in order to hypertrophy (grow) and thus develop (Wylie 2000). We can choose to use floatation aids in the water as resistors, and then the muscular activity changes again! The opposite muscles become concentric and eccentric to the ones used on dry land. The reasons for this change are not fully understood, but the effects of buoyancy whilst in the water, and gravity whilst working in air are thought to have an effect on muscle action.

Figure 2.5 Extension of elbow Biceps eccentric (elongated) Triceps concentric (contracted))

To summarise ● Knowledge of movement, homan kinetics, is essential to ensure aquanatal exercises are both safe and efficient. ● Exercise routines need to be planned effectively to ensure variation and avoid excessive repetition and therefore injury.


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References Aquatic Exercise Association (2006) Aquatic Fitness Professional Manual 5th edition. Florida: AEA. Heyward, V. (2002) Advanced Fitness Assessment & Exercise Prescription 4th edition. Champaign, Illinois, USA: Human Kinetics Publishers. http://www.amputee-online.com/amputee/movements.html (accessed11.8.08). http://www.student.brighton.ac.uk/anatomy/ap.html (accessed 11.8.08). Wylie, L. (2000) Essential Anatomy And Physiology In Maternity Care Edinburgh: Churchill Livingstone Harcourt.

Sources of further information • Images concerned with movement can be obtained from www.primalpictures.com (last accessed 25.05.09). • http://www.shockfamily.net/skeleton/JOINTS.HTML (last accessed 17.11.09).


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Chapter 3 Pool safety – risk assessment and management Aquanatal exercise is designed to be: ● Positively beneficial to health ● Motivational and therefore health promotional ● Socially enjoyable But most importantly it needs to be safe. As health professionals we are constantly mindful of the need to provide care which is of the highest quality and which is therefore deemed to be safe. Midwives have a statutory obligation to ensure the health and safety of the mother and baby at all times (Nursing and Midwifery Council 2004) and physiotherapists similarly need to practise “safely and competently within their defined scope of practice” (Chartered Society of Physiotherapy 2007). The aquanatal coach should aim to ensure similar standards are met within her own practice, ensuring both individual and group safety. Weston, Chambers and Boath (2001) discusses “clinical effectiveness” within healthcare and the need to do anything and everything one can to maximise the quality of care being provided in order to create safe standards. Crafter (2001) considers this in terms of community care and states that quality and therefore safety is the business of everyone providing a social service. Aquanatal exercise is neither a healthcare treatment nor an alternative therapy, as both definitions would require some sort of negative health related starting point. We feel instead, that it can be best defined as a “complementary therapy”, a practice to complement the mother’s changing pregnancy physiology. Having said that, we also see it as an alternative to conventional aerobic exercise, due to it being pregnancy specific; an alternative to swimming, which can be physiologically challenging. It is also an alternative way of accessing pregnancy and parenting information and an absolute alternative to mothers accepting the medicalised model of birth. It can then become a very beneficial treatment, addressing the various problems which can arise during pregnancy, due to its hydrotherapeutic qualities.

Risk assessment In order to assess any potential for creating risk, there always needs to be a thorough appraisal of what the activity is all about, what and who is involved with it, the environment it is to take place in and the subject group who is accessing it. We have illustrated this in the box overleaf.


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Appraisal of the characteristics of aquanatal exercise ● It involves a special social group who are, due to their status, already considered vulnerable and therefore high risk – pregnant women. ● It is provided in a community setting that others have normal and daily access to – the public. ● It is provided in a high risk environment – the water. ● It requires an acceptable level of health from those accessing it – pregnant women. ● It requires a financial outlay and therefore a social contract to be entered into – the leisure service provider (or could be the coach). ● It requires a reasonable amount of energy to complete – the mother (and the coach). ● It involves special precautions – the mother, the leisure service provider, the coach. ● It requires special skill and an understanding of pregnancy physiology – the coach. ● It requires good communication skills – the coach, the leisure service provider.

Having considered the above criteria, the areas of potential risk can be grouped as follows: 1. 2. 3. 4.

The mother The environment The coach The wider public (to a lesser degree).

With these criteria in mind, a thorough risk assessment can now be undertaken. The UK Health and Safety Executive defines risk as “a careful examination of what in your work, could cause harm to people, so that you can weigh up whether you have taken enough precautions or should do more to prevent harm” (HSE 2006). The HSE further highlights five steps to be taken to address risk: 1. 2. 3. 4. 5.

Identify the hazards – anything that can cause harm Decide who might be harmed and how Evaluate the risks and decide on the precautions necessary Document and communicate all your findings Review your initial assessment regularly (certainly if risk occurs) and update your evaluation pro-forma.

In assessing risk we need to utilise all of our sensory and motor skills and our skills of perception. We need to physically walk around the pool environment and see everything. We need to meet other staff and identify their roles within the organisation, so as to have a clear understanding of everyone’s individual responsibilities and a clear appraisal of the communication process to follow should a problem or risk arise, as we do in our professional health roles when inducting new staff, so that we are actively reducing the risk to clients. Aquanatal coaches should also become familiar with all relevant documentation and health and safety guidance as soon as possible and engage in team building and developmental opportunities as and when necessary. These strategies really do help to bond a professional team and increase the overall quality of the service being given. If you decide to be employed by the pool for, say, one hour a week, then you will become a paid employee and subject to the organisation’s code of professional conduct, its rules and its


Pool safety – risk assessment and management staff developmental policy. Very often the pool will fund the cost of single study days and provide you with free CPR and coaching opportunities to enhance your own sessions. We need to ensure that we keep abreast of new developments relating to aquanatal exercise and keep a professional portfolio of suitable evidence of that happening (we offer a sample continued professional development pro-forma in the Appendices). Finally we need to ensure that we document everything and communicate our risk assessment findings to everyone on a need to know basis. The pool management will undertake regular risk assessments themselves, but you need to feed yours into theirs as a matter of good practice. Think RISK! Research the activity and read all instructions Inspect the environment by walking around it and opening your eyes Speak to everyone concerned to ascertain the hazards Keep contemporaneous records safely and ensure you communicate them on a need to know basis. We have considered the law in a separate chapter, but it is nevertheless appropriate here to mention that much of the legislation relating to health and safety originates from Europe and is directed by the UK parliament. The Health and Safety at Work Act (1974) provides the current legal standard and the Management of Health and Safety at Work Regulations (1999) are also applicable. Leisure service and pool providers as employers need to ensure that they are complying with the requirements of the Employer’s Liability (Compulsory Insurance) Act 1969, which stipulates their need to assume responsibility for the health and safety of all employees whilst engaged on their premises and in the work of their organisation. Their annual insurance premiums are affected by the measures they have in place for addressing and minimising risk. We can liken this in the UK to the NHS Clinical Negligence Scheme for Trusts (CNST), which requires all elements of risk to be considered and reduced on an annual basis and which awards those trusts with the most rigorous and robust mechanisms for addressing risk with higher ratings and therefore lower premiums. NHS staff are required to demonstrate their annual refreshment of core clinical skills, such as adult and neonatal CPR, so that their individual practice is as safe as possible. Today, pool managers need to be satisfied that all their coaching staff are suitably qualified and meet at least the basic levels of competence required under their insurance policies. That is why aquanatal exercise coaches need to be suitably certified. You are responsible for your practice and need to ensure that, if working independently (hiring the pool time) you are suitably insured for public liability.

Aquanatal exercise – risks The World Health Organisation WHO (2002) commissioned the Guidelines for Safe Recreational Water Environments (2). This report focused on the hazards associated with community pools generally and it is these hazards that aquanatal coaches need to be mindful of before adding our own. Drowning is the most salient risk and can be categorised into three types: 1. Wet drowning. This is where fresh water enters the lungs and interferes with the process of external respiration by preventing the passage of gases between the alveoli and the systemic capillaries. Haemodilution occurs due to the rapid absorption of water into the bloodstream which then distorts the blood pH balance. The resultant acidosis causes cardiac arrest, which may occur up to 4 hours after the initial rescue. Wet drowning in salt water has the opposite effect, but the same outcome often occurs. As salt enters the lungs, water is drawn into the alveoli from the bloodstream by osmotic pressure. This increases the volume of fluid within the lungs and creates a viscosity within the systemic circulation. The

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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals sluggish venous return eventually decreases the heart rate to the point where, 12 minutes later, a cardiac arrest could occur. 2. Dry drowning. As drowning people sink, and become unconscious, they continue to breathe and this results in water entering the pharynx, which then stimulates the larynx and the epiglottis to close. With the trachea protected, water is diverted into the stomach. In most cases, less than a litre of fluid enters the lungs in wet drowning, compared to several litres entering the stomach in dry drowning. 3. Near drowning. This can be wet or dry, and the difference from actual drowning is that the rescue is successful in terms of resuscitating and immediately preventing death, but the nearly drowned person might experience a build up of fluid in their lungs, leading to pneumonia and in some cases fatal, late or secondary drowning. The reason for this is water entering the body and rapid absorption taking place from the stomach into the bloodstream, causing a distortion of the blood pH. Unfortunately, whilst initially seeming very well, the individual needs close surveillance, as death can occur up to 72 hours later. Spinal injury can occur due to diving in inappropriate depths of water, after alcohol consumption and in pools which are unsafe. Brain and head injury could occur and retinal dislocations due to collisions in the water, when the pool is too full (a reason why we advocate a maximum of 16 people in the pool at any one time). There are other potential risks which are more applicable to aquanatal exercise: ● Hair and body entrapment could occur in the filters around the sides of the pool. We need to advise all women with long hair to tie it back for the session. ● Gastric and other infections may occur if the pool water quality is poor. Checks need to be made by pool staff regularly in order to avoid this risk and it is the responsibility of the aquanatal coach to check all is well. ● Skin allergies can occur. The class need to be advised to shower prior to entering and then again on leaving the pool to minimise risk. ● If the pool water temperature is too cold or too hot, the women attending are at risk of becoming either hypothermic or hyperthermic. This may occur with temperature extremes, for example, above 40 degrees celsius or below 10 degrees celsius and it is generally impossible for a community swimming pool to have these sorts of temperatures. When the water is very cold, vasoconstriction can occur and the mother can experience hypertension. When the water is too hot, vasodilatation occurs and the blood pressure drops. The woman can become drowsy, disorientated and faint as a consequence. As a general rule, the ideal temperature for an aquanatal session is between 28 degrees celsius and 31 degrees celsius. Borjesson and Kinzey (2006) concluded from a small scale study that when pregnant women exercised in chest-deep water within this range, there was no significant difference to individual ratings of perceived exertion (RPE) and in metabolic equivalents, indicating their levels of exertion were similar. Fainting can occur at any stage of pregnancy, but is most common during the second trimester due to the hormonal changes affecting the systemic circulation and to the increasing weight of the uterus in the abdominal cavity pressing on the ascending vena cava and temporarily impeding venous return. If a mother faints in the pool, the aquanatal instructor and the lifeguard will need to respond promptly to the emergency. You will need to immediately put out a “code red” emergency call via the intercom PA system to summon the help of at least two other members of staff, one of whom should manage the rest of the women and ensure they remain safe. Depending upon the section of the class reached, you might be better to evacuate everyone safely. If the mothers have not cooled down, they will need to be supervised in doing so. In the meanwhile the woman will need to be helped out of the water, either by a hoist/net or manually and should leave the pool backwards and upwards, so as to avoid injury to the pregnant uterus against the sides of the


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Pool safety – risk assessment and management pool. She should be positioned in the left lateral recovery position with a flotation aid or other similar wedge under her abdomen. Ensure a clear airway, observe her vital signs and reassure her quietly. Contact her next of kin as soon as possible. An ambulance should have already been called as a precaution. Once recovered or transferred to hospital, complete an accident form. Do not forget to reassure the other women.

To summarise ● ● ● ● ●

Pool environments are potentially dangerous. Pregnant women are considered a high risk and vulnerable group. A systematic risk assessment is essential. The mnemonic “RISK” needs to be remembered. CPR skills need to be maintained.

● Maint ain

Our tips

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References Borjesson, S.R. and Kinzey, S.J. (2006) The effects of water temperature on rating of perceived exertion during pregnancy. Journal of Medicine and Science in Sports and Exercise 38 (5) Supplements: S 356. Chartered Society of Physiotherapy (2007) Rules of Professional Conduct 2nd edition. London: CSP Publications. Crafter, H. (2001) Health Promotion in Midwifery: Principles and Practice. London: Arnold. Health and Safety Executive (2006) Essentials of Health and Safety at Work 4th edition. London: Health and Safety Executive Books. Nursing and Midwifery Council (2004) Midwives Rules and Standards London: NMC. Weston, A., Chambers, R. and Boath, E. (2001) Clinical Effectiveness and Clinical Governance for Midwives. Oxford: Radcliffe Publishing. World Health Organisation (2002) The Guidelines for Safe Recreational Water Environments (volume 2) Geneva: WHO.



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Chapter 4 Getting the best out of your classes It is intended that you read this chapter alongside the session plan offered within the Appendices. It cannot be stressed enough that the key to an effective and safe aquanatal session is thoughtful planning. Petty (1998) considers this to be a salient requirement for any effective learning to take place. This includes good preparation, and time taken for this will pay dividends in terms of the success of your sessions. A streamlined and relaxed session will encourage clients to value your service, recommend it to others and continue to come along each week. Interestingly, good established classes never need to formally advertise, as the clients themselves do it for them! Working to a realistic and structured session plan is essential and this begins with acknowledging how long the actual class should last. The Aquatic Exercise Association (2006) recommends that mothers are in the water for no longer than 45 minutes to complete all components of a session, as they will burn up between 400 and 500 calories during this time, which is a considerable amount of energy consumption to deal with during pregnancy. It needs to be remembered that energy, in the form of glucose metabolism, needs to be prioritised for the developing foetal brain. Mothers should therefore be advised to have a carbohydrate snack prior to the session and/or bring an energy drink to the pool. Within a 45-minute aquanatal session, therefore, there needs to be a sensible, safe and realistic progression of muscular activity. By combining periods of low intensity with short bursts of medium work, the session can provide a holistic workout which creates some moderate cardiovascular stress and some muscle overload, but also avoids over-exertion and distress. The five main components of an effective session are generally considered to be: 1. Warm up (approx 10 minutes) 2. Aerobic curve (approx 15 minutes) 3. Muscular strength and endurance (approx 10 minutes) 4. Cool down/short stretch/flexibility (approx 5 minutes) 5. Relaxation and revitaliser (Invigorator) (approx 5 minutes) You also need to include an introduction, which serves to welcome and offer safety information and a farewell, which thanks the group and provides them with a feel good factor (Baum 2000).

Warm up 1. The warm up component consists of three elements (the mobiliser, the pulse raiser and the short stretch) and ideally should last for 10 minutes or so. Actual times are not rigidly set, as there might be external factors which necessitate either a longer or shorter warm up, one being the water and ambient temperature of the pool.


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Mobiliser In the interests of safety, it is always a good idea to conduct the mobiliser statically, so that the class can begin to get a feel for the pool environment, the pressure of the water and the condition of the pool floor, so as to avoid slipping. Gentle, short lever exercises are a good idea here, as they aim to mobilise the main joints of the body and prepare them for further work. Ensure that there is equal consideration for upper, middle and lower body exercises to provide a balance. As well as the joints being prepared, the lumbar spine needs to be made flexible so the belly dance and pelvic moves can also be introduced at this time, working the abdomen and lumbar spine, and making the pelvis more mobile (Baum 2000).

Pulse raiser During the warm up, you, as class leader will need to get the group’s attention and so engage their confidence, so a catchy, rhythmical piece of music is a great way to get them started. The pulse raiser aims to do just that and increase the intensity of the work out a little more by working on the cardiovascular system. It is a good idea to choose both some short and longer lever movements here to provide variety and interest. It is good to lead your group across the shallow end of the pool both horizontally and diagonally in order to begin to generate water turbulence which will support effective exercise techniques. Care needs to be taken, however, to limit intensity so that a gradual warming up will occur and the women have time to adjust to movement in the water. For example, the hands initially need to be in slice mode which is a simple and easy position to enable streamlined movement. As a coach, you will also need to ensure that you move the group cohesively in all directions and for that to happen they will need to be able to see you clearly. Take care therefore to move around all sides of the deck (pool side) and use definite arm movements to highlight your instructions and keep the attention of the class on what you are trying to teach them (air hostess arms).

Short stretch The final section of the warm up component includes a very short upper, middle and lower body stretch, which aims to further prepare the joints and muscles for more physical work. It is perfectly acceptable, however, to omit this final warm up component in a cooler pool environment, as reverting back to static work following an initial period of movement, albeit of slow intensity, might cause the body to cool down excessively and it needs to warm up.

Figure 4.1 Coach in warm up mode


Getting the best out of your classes

Aerobic curve 2. The second main component, the aerobic curve, is designed to last for approximately 15 minutes; again the coach needs to decide the length of this component based upon her judgement of the group and of the pool environment. It aims to provide a controlled and gradual cardiorespiratory response and culminate in a flat peak which provides a higher level of exercise intensity.

Build up The first element of the aerobic curve is termed the build up and, in order to be effective, needs to last for about 5 minutes. Choose exercises which follow on from the pulse raiser part of the warm up here and allow for further movement in the water. Frequent directional change enhances the way water swirls around the body and therefore turbulence can be used to its maximum effect. Care needs to be taken, however, to ensure these movements are controlled, especially in near to term women, as core stability can be compromised and round ligament pain can be induced. Of particular use are exercises which require the women to form and move around the perimeters of circles and to move from inside to outside, either individually or in pairs or small groups. The class needs to be kept moving, to develop the exercise intensity, but they also need to see each other’s faces and communicate verbally.

Flat peak The second element of the aerobic curve is termed the flat peak; it was previously referred to as the plateau. It usually lasts for approximately 5 minutes and involves long levers and more directed movement around the pool. Games are useful here, such as “The Grand Old Duke of York” which requires the women to move across the shallow end in pairs and then in groups of four and then as one whole moving wall of water.

Build down The third element of the aerobic curve is the build down. This aims to return the body to its pre-peak status, by utilising either the same exercises used in the build up section or similar. Its duration is also similar.

Muscular strength and endurance (MSE) 3. The MSE component aims to tone and strengthen warm muscles. It can be likened to gym work, in that various aids can be used to provide resistance and repetition. The MSE also includes exercises which target the pelvic floor and is therefore designed to last for approximately 10 minutes. As muscles tend to work in pairs, care should be taken to plan a holistic range of exercises to target muscles of the upper, middle and lower body. Remember if the water temperature is cooler, the body will be working harder and therefore this component might need to be interspersed with some low intensity movements to maintain body temperature and exercise efficiency. Our tips for the MSE section ● Plan one exercise for the upper, middle and lower body. ● Utilise floats or woggles as resistors. ● Ensure the group are warm – check by asking them, observing them and monitoring their behaviour. ● Explain to the mothers each set of muscles you are working and what the benefits will be. ● Provide positive feedback; consider the many ways you can say “well done”! ● Ensure there is enough time to perform pelvic floor exercises. ● If there is a large group of mothers, to avoid having to raise your voice to be heard when undertaking pelvic floor exercises, consider splitting the group into two halves. One can be having a social chat whilst moving with the aid of woggles in one corner of the pool, whilst the other stays with you whilst you explain and guide (then change over). This strategy is particularly useful if there is a male lifeguard in attendance to avoid embarrassment.

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The pelvic floor is further discussed in Chapter 8.

Some exercises for targeting the pelvic floor: The zipper Rest your group in “Sea Horse” woggle mode (sitting on their woggles like sitting on a horse) and invite them to imagine they are slowly pulling up their jeans zipper whilst tightening up their pelvic floor. When the zipper has reached their umbilicus, tell them to slowly release (open) it back down again. In doing this, they can experience the lifting of the pelvic floor muscles and also their relaxation. Do ensure that the class continue to breathe normally and do not hold their breath. Flower petals Positioned as before, ask your group to imagine an upside down daisy in front of them. The flower begins to change, with the white petals slowly closing over the yellow centre. At the same time, they need to be replicating this movement themselves with their pelvic floor muscles and then returning to the open position and relaxing.

Figure 4.2 ‘Sea horse’ woggle position

The elevator Sitting on their woggles again, ask the group to visualise entering a lift in a store. They press the button to get to the first floor whilst at the same time tightening their pelvic floor and lifting the muscles a little. By pressing the second and third floor buttons, their pelvic floors are lifted even more. Once at this level, they can come down slowly, floor by floor, or more quickly by instantly releasing their muscular grip on their woggles. “Moving bones” (optional use of woggle) Demonstrate with the aid of a pelvis or a laminated picture, the location of both the pubic and coccyx bones. Ask your group to imagine that there is a very strong elastic band connecting them from front to back and that, as the band gets shorter, the bones move closer. Articulate when the band is getting shorter. Afterwards, show the group the pelvis in a sitting mode with an elastic band connecting the ischial tuberosities becoming closer together as the band shortens. This visualisation seems to trick the mind into tightening and moving the pelvic floor muscles upwards. Repeat the exercises at least twice. Traffic lights Ask the group to imagine they are sitting in their car at the traffic lights. The lights change from green to orange through to red. At the same time, they need to tighten their urethra, vagina and then anus and all the time the light is on red, they hold the tension, only releasing it when the lights change slowly back to green. Advise the group, however, not to do this whilst sitting in their car at real traffic lights as it can lead to a loss of focus and might distract and lead to an accident.


Getting the best out of your classes

Cool down/short stretch/flexibility 4. This component (optional, depending on the temperature of the water) lasts for approximately 5 minutes in total and aims to prevent post-exercise stiffness and therefore soreness. Although, as previously highlighted, water based exercise results in less soreness generally anyway due to all muscles being worked in concentric mode with little lactic acid build up. Choose slower music (good beat around 70–80 beats per minute) and plan to offer one stretch for the upper, middle and lower body. All stretches should be undertaken in static mode with each lasting approximately 20 seconds. A simple way of organising this component is to repeat the short stretches undertaken in the warm up component.

Relaxation and revitaliser Relaxation 5. The relaxation component (2 minutes approximately) aims to provide the pregnant exerciser with a feeling of total body well being and a reward for engaging in the exercises. She is able to engage in a variety of techniques to aid her psychological and physiological relaxation in a safe and supervised environment. Many relaxation strategies are dependent not only on the water temperature but also the size of the group. Music should be soft, calming and smooth. Some ideas are: ● Whole group circle float – the coach asks everyone to form a circle and hold hands. Then every second woman is asked to float, whilst the others side step around the circle and create gentle movement. After a minute they change position. The instructor needs to be vigilant in order to ensure the group does not drift and accidentally bump into one another.

Figure 4.3 Group circle relaxation

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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals ● “Rickshaw woggles” – the women are asked to choose a partner. One woman stands and holds a woggle in each hand; she faces forwards. The other partner holds the end of each woggle behind her, lying backwards; she is pulled slowly by her partner whilst gently flapping her feet. They change over after a minute. This component has the added benefit of building relationships and kinship within the group, as the women tend to talk quietly to each other, share information and offer peer support, all valuable in stimulating a fertile learning environment Kaufman (2007). Our tips for the relaxation section ● Adopt a helicopter view of the whole group. ● Use this time to move around the group and offer advice. ● Be aware that some women do not like social touching so determine this individually beforehand. ● Some women do not appreciate getting their hair or make up wet. So offer alternatives for relaxing. ● Third trimester mothers should not lean forwards in this section to avoid lumbar lordosis (back pain). They should be semi-recumbent on the woggle or, if they wish to chat, in ‘sea horse’ mode to keep the spine in neutral position. ● Ask the group to gently scroll their hands if they are becoming cold. ● Consider omitting this section if the water temperature is too cold.

Revitaliser The revitaliser component (3 minutes in total approximately) aims to return the group to an alert state of mind and send them home feeling good. This component is essential in order to normalise systemic blood pressure following a period of inactivity and relaxation, in order to avoid the risk of fainting and injury. One method is to snake the group around the pool whilst holding their woggles in front of them with both hands and adopting a rowing motion. They can finally arrive at the pool steps for an orderly and controlled exit. As you develop your aquanatal coaching skills, your repertoire of revitalising strategies will increase. Consider the ‘Conga’, the ‘Hokey Cokey’ ‘The YMCA’ and the ‘Can Can’, for example. Quite loud and fun music needs to be played during this component with a beat of 120–130bpm. If the group are sent home happy, they are far more motivated to return next week! Finally, to deck or not to deck?

Figure 4.4 Professional coach


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Getting the best out of your classes You must be on deck (the side of the pool) for the start of your session (warm up component) in order to give clear health and safety advice and to demonstrate specific body moves. However, there is much controversy and professional debate regarding the need for the coach to then enter the water with the group or to remain on deck. We feel there are benefits from both approaches, but err on the side of entering the pool from the start of the warm-up component. We base this on a variety of reasons, including being better able to engage with your group, being able to move at the same pace as your group and ensuring your own safety by demonstrating the exercises in the medium they were designed for and not on dry land. There is only one counter argument, that of the group not being able to see your moves when in the water, but careful planning and initial demonstration will address this in our opinion. When on deck, all eyes will be on you, so your posture and moves must be clear, with effective cueing of your chosen music. Your clothing should be professionally appropriate for both in and out of the pool; a swimming costume worn with cycling shorts is best, in dark colours, so your silhouette will be clearly defined. Socks and trainers are essential, as the trainers stop you slipping on deck and the socks will prevent unnecessary slipping on the tiles when walking and moving in the water.

To summarise ● In order to get the best out of your classes, it is essential to plan effectively and act professionally. ● There are five main components of an aquanatal session: ● Warm up ● Aerobic curve ● Muscular strength and endurance (MSE) ● Cool down/short stretch ● Relaxation/revitaliser ● The whole session should ideally last no longer than 45 minutes. ● The session should offer a total body work out in a safe and fun environment. ● Offer exercise for the upper, middle and lower body and avoid unnecessary repetition. ● Choose music thoughtfully and avoid loud and high beat music when performing static stretches. ● Remember to include pelvic floor work in the MSE component. ● Only include the cool down and relaxation components if the water temperature is warm enough. ● Send women home on a high, by including a revitaliser component.

● Atten d as many aquanatal ideas

Our tips

from oth sessions ers. as you ca n to get ● Try t o attend a t least on update (id e full day eally at le annual ref ast three resher/ ● The c d a y s ). oach ente ring the w onwards ater for t supports he warm t h o s session. e teaching up sectio n a physica lly demand ing


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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals References Aquatic Exercise Association (2006) Aquatic Fitness Professional Manual 5th edition. Florida: AEA. Baum, G. (2000) Aquarobics: The training manual. London: Harcourt. Kaufman, T. (2007) Evolution of the Birth Plan. Journal of Perinatal Education 16 (3) Summer. pp 47–52. Petty, G. (2002) Teaching Today: a practical guide (2nd edition). Cheltenham: Stanley Thornes (Publishers) Ltd.

Useful sources of information and contacts www.simplyswim.com for swimwear and pool resources (last accessed 02.04.09). www.mailsports.co.uk for a wide selection of aquatic clothing and equipment including swimming costumes and “Swimskins” (all-in-ones) Phone No. 01628 529206 (last accessed 02.04.09). www.pureenergymusic.com for aquatic exercise CDs (membership required) (last accessed 02.04.09).


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Chapter 5 Aquanatal choreography This chapter aims to consider the use of music within an aquanatal session. It will also consider how the coach, by developing an understanding of choreography, can enhance her routines to be not only safe and effective but also to be creative and therefore enjoyable. Choreography is defined as the art of setting motion to music and therefore creating movement that is both meaningful and motivating (www.calainc.org). It needs to be acknowledged from the outset however, that the use of music within sessions of water-based exercise is controversial, due to a belief that when music is played not everyone can move effectively to its beat and this can result in injury. This is based on how individual bodily characteristics and level of general fitness can affect ability to move in time to the music. However, these factors are also pertinent to dry land exercise and can be just as effectively managed within the water environment, by adopting a similarly professional approach. The aquanatal coach therefore not only needs to understand how different body types move in the water, but also how to ensure the selected music can support particular levels of fitness. Good planning is salient and the coach needs to ensure that, for some mothers, the exercises can be either progressed (made more difficult or resisted) or adapted (made easier or supported). By utilising her knowledge of the properties of water, the coach can select a generic piece of music with a beat which will accommodate everyone’s needs. The inclusion of music can be interesting, as it can be both motivational and relaxing, depending on its beat and tempo and can therefore add fun and provide a feeling of total body well being for those attending the session. Care needs to be taken, however, in selecting the most appropriate piece of music to fit each component of an aquanatal session and also to ensure that it is not played too loudly so as to interfere with verbal cues. The coach should not be in competition with the music and needs to remain the focus of attention at all times. However, it needs to be acknowledged that pool acoustics are generally poor and can drown out the music so its volume needs to be appropriate. Another concern is the type of music being played, as not everyone shares the same taste. In order to address this, the coach needs to play a variety of music including pop, middle of the road, smooth and classical pieces. A combination of vocal and instrumental tracks are also useful. Ages vary within the group, but generally (from our experience) most like music from the sixties, seventies and eighties and particularly bands such as Abba and the Beatles. Music can be used for background, cueing (signalling a change of movement, or sequence) or to plan a sequence of movements within, for example, a particular verse or chorus. However music is to be used, the coach needs to acknowledge that the humid pool environment will ultimately affect the lifespan of her equipment and her CDs and therefore will need to plan to replace as necessary. You also need to ensure that all music played within a session has a public performance licence(from www.ppluk.com) and is therefore legal. It is useful to have a library of CDs and to alternate them each week so as to create interest and avoid the class becoming bored and also to lengthen the CDs’ lifespan and save money.


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Understanding music The terms beat and tempo are frequently referred to when describing a type of music. Beat indicates regular pulsations (or rhythms) that can be counted when listening to a piece of music. Tempo is the rate of speed at which the beats occur (AEA 2006). According to Mehanni (www.mariettamehanni.com), one basic way of counting the beats and assessing their speed is by tapping or clapping the hands and then moving on to grouping them into lots of 8. Every time you reach 8 draw a stroke on the page (l) until you have 4 strokes ( llll); the maximum number of strokes on any one line is 4. This is then referred to as a block of 32 counts (4 lots of 8) After doing this, play the piece of music again and name the blocks: introduction, chorus, verse 1 and so on. You can then select exercises to fit each block. If this proves difficult, simply listen to the piece of music and instead of counting, write down the names that help you identify sections in the music such as the chorus and first and subsequent verses for example. Most music is broken into 32 bar choruses, creating a recognised format and hopefully memorable tune. A wonderful website to explain this can be found at www.swingshift.com. As a general rule, if an exercise is performed in water, it will take double the time to achieve, due to the water’s resistance, than if performed on dry land. Therefore half tempo (speed) is very often referred to. There is a general consensus that a tempo of between 120 and 150 beats per minute is appropriate for an aquanatal session, to ensure the exercises are efficient but also to avoid strain and injury. Many factors can affect this, including individual characteristics of the group and the depth of the water they are working in. Shallower water enables easier movement. Having chosen a piece of music, appropriate exercises now need to be selected. In choreography, the exercises are referred to as moves and can simply be the raising of a leg. This first movement is then the basis for a transition or a change from this primary one to another. If still considering the leg, this might now be to flex the knee. All exercises need to be broken down into their moves and then reassembled to fit the musical beat and tempo. The number of repetitions of a particular exercise will also need to be considered in order to fit the beat. Care needs to be taken, however, to ensure that there are not too many repetitions of one particular exercise, so as to avoid strain and injury and this is why the aquanatal coach needs to choreograph her session and thus plan what muscle groups she is working.

How to plan effective choreography All moves start from a basic (base) move, which can be as simple as marching on the spot or a side step, and from this the next move is added, creating a flow of movements which will need either adapting or progressing as the individual mother’s characteristics and those of the pool are considered First isolate each move into descriptive and pictorial building blocks; the use of matchstick people is useful with brief notes. The movement can then be defined and reorganised in time order, by layering each diagram one after another. Once rebuilt, the moves will become patterns which will flow seamlessly and thus be logical to both you and to the group, when demonstrated (Wikipedia 2008).

Warm up Starting with the warm up component and the mobiliser, list any exercises you consider to be appropriate. Remember that you are aiming for the group to lubricate and mobilise their joints and also to focus on you. Your chosen music needs to be bright and welcoming although not too loud and therefore a beat of approximately 120 beats per minute is suitable. A suitable track might be Lifted by The Lighthouse Family, for example.


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Aquanatal choreography

Warm up and mobiliser – exercise examples Move

joint mobilised/increased flexibility

Repetitions

Static marching

hips/knees/ankles

X 16

Shoulder rolls back/forward

shoulders

Back 8 X Forward 8

*Cutting a diamond

shoulders/elbows/wrists

X8

**Sweeping arms L to R

shoulders/elbows/wrists/hips/knees/ankles

Right4 X Left 4

***Pelvic tilt/hip circles

increased flexibility in the lumbar spine

Right 8 X Left 8

Leg bends

hips/knees/ankles

X8

Leg raises

hips/knees/ankles

X8

Dumbbell arms/spot march

elbows/wrists/hips/knees /ankles

X 16

Slow funky chicken

shoulders/elbows/wrists/hips/knees/ankles

X 16

Spot skipping forwards/back

all of the above

Forward 8 X Back 8

(See Chapter 2 for description of exercise positions, and session plan in Appendices.) (See Figure 5.1 Cutting a diamond Figure 5.2 Sweeping arms Figure 5.3 Hip circles)

Start with a simple base move such as lifting the leg for the march and then develop it by perhaps adding short lever arms. Leg raises and on the spot skipping, leg bends and then sweeping arms from side to side (remember to keep the knees in soft mode when performing this exercise). As discussed in Chapter 4, the pool can initially feel cool and if this is the case, static movements can be interspersed with either slow skipping or spot marching to enhance exercise efficiency.

Figure 5.1 Cutting a diamond


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5.2 Sweeping arms

Figure 5.3 Hip circles


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Aquanatal choreography The pulse raiser is the second part of the warm up component and involves moving on and increasing the intensity of the exercises or beginning work the joints and muscles and start some cardiovascular exercise; in order to achieve this, some movement across the shallow end of the pool is required. Starting with spot marching is a good idea; then indicate to your group verbally and cue them visually that they are about to move off to their left whilst side-stepping. Remember to offer ongoing verbal instructions, such as “take only small steps”, “maintain hip direction forwards”, “place feet carefully on the pool floor to avoid slipping”. Begin the movements in a slow deliberate fashion as the chosen music dictates and once the group have achieved the abductor/adductor leg movements to their left and right, you can progress the exercise by bringing in short arm sweeps, whilst continuing their movement in the water. Towards the end of this section, you will need to increase the intensity a little by making use of further directional change and thus creating frontal resistance, a “wall of water”. Baum (1998) refers to this as a “Random current” which serves to increase the effort associated with movement in the water and thus begins to prepare the body for further aerobic activity. By demonstrating on all three sides of the pool (deck) you will encourage your group to move with you in the shallow end and you will be able to put them through their paces backwards and forwards, changing direction frequently, but in a controlled manner. Your chosen music needs to be a little bouncier than your previous one, with a beat of approx 120–125 beats per minute, but do ensure that any vocals do not drown out your verbal instructions. A suitable track here might be Take a chance on me by Abba, for example.

Pulse raiser – exercise examples Base move

Progressive move

Repetitions

Spot march

Side step left/right – hands on hips Small lever “breaststroke arms” With roly-poly arms

Across shallow end twice Across shallow end twice Forwards and backwards twice

These basic moves tend to work well, as they allow for the group’s intensity of movement to be structured and therefore safe. The third and final part of the warm up component involves a short static stretch to prevent muscle injury created by further exercise, but this may be omitted if the water temperature is too cold or if short stretches have been intermittently included in the pulse raiser section. Remember, only warm muscles must be stretched and if they are to be included as a separate part, they can also be interspersed with some wide range body movements to prevent cooling whilst static. Please refer to the session plan or visit www.waterwellnessworkouts.com for some ideas. Suitable music here might include an instrumental piece of classical music or perhaps Watermark by Enya. This has no beat, so as to encourage smooth linear movement and thus avoid injury. You should remain on the pool side for the entire warm up section, so your group can visually observe your posture and practice the basic moves and stretches safely. There is much professional debate regarding if and when the coach should enter the water. However from our experience and careful consideration of the arguments, we recommend a pragmatic view, based on safety, and suggest that you enter the water after the warm up section. An effective warm up will have enabled the class to see your legs working and further stretches can simply be repeated but for a little longer. Close contact in the water will also allow you to see and to amend their movements as necessary and to protect yourself as you are doing so.


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Aerobic curve For the second section, the aerobic curve, you will be in the water with the mothers adopting a helicopter or peripheral view of the group as a whole. You need to create a gradual build up to an aerobic peak and then return to where you began at the beginning of the aerobic section. The aim here is to further develop a moderate cardiovascular response and the class therefore need to become slightly breathless. Do please refer to the Borg scale of exercise intensity to ensure they are not overdoing it. The talk test is also of use, as if still talking, mothers are not being placed under undue stress.

The Borg (1970) scale for assessing perceived exertion (adapted from Borg’s Perceived Exertion and Pain Scales. Borg, G. Human Kinetics 1998. (www.humankinetics.com)

6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

No exertion at all Very, very light Very light Fairly light Somewhat hard Hard Very hard Very, very hard Maximum exertions

It is generally accepted that pregnant women, when exercising aerobically, should be working within the 12– 14 range and this is categorised as “moderate intensity” (AEA 2006). The current recommendation is that healthy pregnant women need to engage in physical exercise, as it is valuable to their health and future well being (Dempsey, Butler and Williams 2005). However, if not working to this intensity their efforts will be of little use. But alternatively, if they exceed this moderate level of intensity they could place their own and their baby’s health at risk, due to the effects of the body overheating, resulting in maternal dehydration and foetal tachycardia. This could be detrimental to your professional credibility; it will almost certainly prevent them returning to your sessions and possibly lead to them suggesting that friends and peers do the same. The aerobic flat peak is where you can really have fun with your group in the water, by incorporating big moves into a simple routine. You need to keep the group moving whilst aiming to achieve a gradual increased cardiovascular response and training effect. This can only be accomplished by considering the duration and effort required for the entire section however. Choreograph music to motion carefully therefore. Moves can be progressed, by directional change, changing the length of levers, considering the body’s position in the water and changing the hand positions or using water mitts to ensure the larger muscle groups are working at an enhanced level. You need to consider bouncy, lively and fun music here, with a beat of approximately 125–135 beats per minute, to encourage group interaction, movement and enjoyment. Remember, however, to build up the intensity and then to return it after the peak. Three to six tracks of music (depending on their length) of a developing beat will allow for this. Consider the type of music, instrumental or with lyrics, as if the class can sing along to the words or move in time to the beat they tend


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Aquanatal choreography to feel good and this will minimise their perception of the exercise intensity. It then becomes quite pleasurable due to the natural endorphin release. Consider tracks such as Spinning around by Kylie Minogue, Reach by S Club 7 and Dancing Queen by Abba. Seventies and eighties music is also useful here if it has a good beat. Almost everyone knows some of these tracks and you will find the group singing along to them as they move around the pool.

Aerobic moves – examples Circles and snakes are an easy way of maintaining a flow of movement as are nursery dances such as the “Grand Old Duke of York”. Such moves can be great fun and help encourage friendliness and group interaction. Ensure that everyone gets a turn at marching up and down. This is also psychologically useful in helping some mothers to retrieve their childhood memories perhaps and consider their child’s future happiness. For others, it might be a way of experiencing these activities for the first time and therefore being allowed to have fun. A ceilidh dance routine using ‘braiding’, (country dancing movements such as weaving in and out) or linking arms as in ‘Strip the Willow’ or the “Gay Gordons” always works well, as there is lots of water movement, swishing, swinging and turns involved (www.gerryjones.me.uk). Circles work well, especially if you surround a small moving circle with a larger one and move the inner and outer circles in opposite directions, progressing further by directional change and the addition of chopstick arms and underwater clapping. Spotty dogs (the exerciser moves the arms and legs as if jogging, then to progress the exercise the arms and legs are locked straight, making it harder to move) are also useful. Jumping jacks work shoulders, thighs, calves and the back in an aerobic way. Simply, they involve standing with the feet together with a good posture, bending the knees slightly and making small jumps, moving the feet apart. However, in pregnancy the feet should not be extended wider than hip width, as this might result in pelvic instability. The feet are brought back together. The arms can be extended and returned at the same time as the feet. Do these exercises moderately. With a little imagination and innovation you can create a super routine for achieving aerobic exercise.

Muscular strength and endurance During the muscular strength and endurance section (MSE) you need to utilise any additional resources you have at your disposal to create water resistance. Woggles, rubber dumb bells, balls and polystyrene floats are extremely useful, but so too are the participants themselves and the pool walls. MSE work needs to be undertaken in a controlled environment, so choose music with a slower beat, perhaps around 110 beats per minute if undertaking static exercises or 120 beats per minute if moving around the pool. Consider using the music for background purposes only, so as to provide some interest and ambience but to avoid competing with your coaching points. Appropriate music might include classical or instrumental tracks, lively piano or panpipe music (with a beat) and minimal lyric tracks.

Muscular strength and endurance – exercise examples (Remember to include exercise for the upper, middle and lower body Exercise (Upper) Triceps pushdown Chest press woggles

Adaptation

Progression

Duration

Nearer surface with one knotted woggle Slower movement

Deeper or with two woggles Harder “push”

30–60 seconds 30–60 seconds


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Exercise

Adaptation

Progression

Duration

(Middle) Side pushdowns With woggle/float

Modify position in water

Consider two aids

30–60 seconds

Consider intensity and repetitions

30–60 seconds

(Lower) Woggle press down Adapt intensity and reps and lift with alternate foot (ensure no symphysis pubis dysfunction) (Pelvic floor) For ideas see Chapter 8

Cool down In the cool down/flexibility section, music is best presented without a beat, or with a subtle beat. Lengthier static stretches are indicated here and movements need to be smooth and considered. The coach might simply choose to repeat the short stretches undertaken in the warm up section, but will need to ensure they correspond with the muscles worked most throughout the session. If music is chosen with a beat, it should be no more than 80 beats per minute. Suitable music here is soft, smooth instrumental or soft vocal such as Run Away by the Corrs or When We Dance by Sting.

Flexibility section – exercise examples An upper, middle and lower body stretch, lasting in total 2 minutes (1 track of music) Upper – “Bear hugs” (trapezius, pectorals, biceps) Middle – Side stretch (the obliques) Lower – Calf stretch (gastrocnemius and soleus) All can be adapted or progressed by considering the timing.

Relaxation and revitaliser (invigorator) The relaxation and revitaliser section requires the selection of music and choreography which will provide a sense of complete mental and physical relaxation followed by a final fun activity to send the class home happy. Our suggested music for relaxation includes Clannad, Enya, the theme tunes from the movies Out of Africa or Titanic, or any relaxation CDs such as water music, or birds singing. Moves can include the women floating individually with their woggles, or group circle floats, and if the water is cooler, consider Rickshaws where one woman floats holding on to a woggle in each hand whilst her partner pulls the other ends of the woggles forwards. Both then change over, by one simply leaning back and floating and one standing and walking forward. To end the session, choose a loud, fun track with a good beat (130–135 beats per minute); we suggest, Amarillo, the Conga, theme tunes from James Bond, YMCA or the Can-Can. The aim is to send everyone home happy so that they will return to your session the following week.


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Aquanatal choreography

The use of music and copyright (See also Chapter 13 The Law and aquanatal exercise) It is illegal to play music in a public setting without a licence as it is classified as a public performance. It is also illegal to purchase music and re-mix it on to a separate CD, for example, for use in your session or to copy commercial sound recordings without the necessary permission. Aquanatal coaches therefore need to ensure that they have public performance licensing (PPL) in place before playing any music for a session. Usually, the pool provider will already have this under a block licensing scheme. However, you need to check. Do contact www.ppluk.com for further help and advice. Packages can be purchased from various companies which enable you to buy compilation CDs for your sessions from original artists which are also PPL approved. We offer some of these at the end of this chapter. An alternative is to bring a collection of your own CDs (original artists) to the pool and change them as necessary, but this is time consuming and does not lend itself to the seamless and therefore effective provision of a session. You will still need a PPL licence to do this, however, unless your pool provider has one. Do consider the use of music within your sessions. It has many benefits including adding interest and ambience, encouraging enjoyment and fun. It can also motivate and stimulate, aid relaxation and enhance well being. However, if not used considerately it can de-motivate if the music is not liked by the group; it can create confusion if its beat is inappropriate to the moves selected, and if played too loudly so as to drown out essential coaching points it can be dangerous.

To summarise ● Choreography is the art of setting motion to music. ● Beat indicates the regular pulsations or rhythms and tempo is the rate of speed the beats occur. ● The use of music within an aquanatal exercise session is controversial; there are reported benefits and disadvantages. ● Benefits of using music include increased motivation and fun; it can help create an atmosphere and it can aid relaxation and a feel good factor. ● Disadvantages of using music include de-motivation if the chosen music is not liked by the group; it can be played too loudly so as to create risk and can create movement confusion if the incorrect beat is chosen for the move. ● Public performance licensing (PPL) is required if playing music in a pool. ● The pool environment can shorten the life of music players and CDs.

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Our tips

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Our tips

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References Aquatic Exercise Association (2006) Aquatic Fitness Professional Manual 5th edition. Florida: AEA. www.humankinetics.com Baum, G. (1998) Aquarobics: The training manual. London: Harcourt. Borg, G. Borg’s Perceived Exertion and Pain Scales. Human Kinetics 1998. www.humankinetics.com (last accessed 18.12.09) www.calainc.org (last accessed 06.10.08). Dempsey, F.C., Butler, F.L. and Williams, F.A. (2005) No Need for a Pregnant Pause: Physical Activity May Reduce the Occurrence of Gestational Diabetes Mellitus and Pre-eclampsia. Exercise and Sport Sciences Reviews 33 (3) 141–149. http://enwikipedia.org (last accessed 12.10.08). www.gerryjones.me.uk (accessed 23.11.09). www.waterwellnessworkouts.com (accessed 01.04.09). htpp://www.ppluk.com (last accessed 13.11.08). www.mariettamehanni.com (last accessed 01.02.09). www.swingshift.com (last accessed 13.11.09).

Useful sources of information and contacts: • • • •

www.Jumpybumpy.com for exercise courses, choreography, exercise music and videos and clothing (last accessed 13.11.08). Pure energy – 01709 710 022 (UK) for Aquanatal insurance, PPL Licensing and music. The Register of Exercise Professionals (UK) 0845 601 6067 for advice, professional insurance and continuing professional development. Telstar – 08705 133 777 for PPL licensing and music.


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Chapter 6 Practical tips for more fun and interesting classes It can be said that we are all creatures of habit, finding solace in at least a couple of personal lifestyle routines. Routines are also valued within clinical health care as a tool for helping to minimise risk, promoting safety and ensuring services are equitable due to their systematic structure. Midwives are constantly being challenged to change practice in light of best evidence, but are also still being required to routinise some elements of the care offered to mothers, due to their being deemed efficient and of benefit to the service. It could be suggested therefore that we benefit in terms of having some routines for safety and therefore professional security, but also in not having too many and preventing the creative development of services. Aquanatal exercise coaches need to balance professional creativity with the need to be safe. Routines can be useful therefore, if used appropriately to provide a sense of safety and comfort for exercising mothers, whilst the inclusion of some new material each week will add creativity and interest and will serve as a motivator. Mothers will come back to your sessions if you get a balance in this way by planning your exercises carefully. Think: safe, effective and fun! You will need: A library of different CDs A folder of different session plans (see the appendix section for a sample pro-forma which can be photocopied) A collection of resources to support your class such as woggles, floats, laminated charts, cards and some general household items. Here we offer some ideas for safe, effective and fun activities that can add interest and creativity to your sessions:

“The waiter” This is a useful exercise for the aerobic component. Circle your group and keep them moving around the circle behind each other. Select a participant to step out of the circle and direct her to move in the opposite direction (fig 6.1). Add to the turbulence and fun by giving the outside runner a float with plastic cups filled with water or an array of rubber ducks! When she has completed a circuit without dropping the tray and its contents, she re-joins the main group and taps the shoulder of the mother next to her to replicate her actions. This is a really fun exercise which also supports group dynamics.


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Fig 6.1 ‘The waiter’

“Pass the parcel” A water based version of the popular children’s party game which can be added to the aerobic component or used as a revitaliser, following the relaxation component, to focus attention at the end of the session. For this you will require a small gift; we suggest that you purchase something for the mother or an item which may be of use to her either in labour or following the birth. Gifts need not cost a lot, or you might consider asking local companies to donate a couple of items or seek help from your local Children’s Centre. Wrap the item in several layers of plastic wrapping paper; the printed type that florists use is ideal, as it is not completely transparent. Have the gift on the edge of the pool side within easy reach of each woman and play the music whilst moving around as a circle. When the music stops, the woman nearest to the gift removes a layer until finally there is a winner. Classes obviously like this game as they can leave the pool with a gift and for some this can be materially helpful.

“Over the rainbow” This is a fun exercise for the revitaliser component and involves the whole group. Direct the class to stand in two lines each facing a partner. Ask each woman to give one end of her woggle to her partner. The woggles are held overhead, creating a rainbow effect. The first couple then make their way under the arch of the woggles and reform at the end themselves raising their woggles aloft again. As facilitator you can decide where the rainbow will end; one idea is by the pool steps to indicate the end of the session. Mothers can then leave the pool, placing their woggles on the pool side as they do so.


Practical tips for more fun and interesting classes

“The knotted woggle” This is a fun exercise for the MSE component and is particularly useful when facilitating pelvic floor exercises for a larger group of mothers in order to maintain a degree of intimacy. Split your group into two halves and give everyone a knotted woggle. Direct one half away for a chat and a couple of circuits of the shallow end of the pool. They will need to push their woggles in front of them to create turbulence as they move around. Meanwhile huddle the other half in a smaller group to one side of the pool, preferably so they can see a large colourful laminated poster of the pelvic floor and hopefully a model of the pelvis. You can explain a simple exercise here (for ideas, see the chapter regarding the pelvic floor) whilst maintaining a helicopter view of the others. Complete the exercise by changing over the groups.

“Circuit training” Consider this woggle workout within the MSE component. It helps create variety and interest. Select half a dozen MSE exercises; draw them as screen beanies or giant matchstick men on to large laminated cards. Include a concise description of the exercise and muscles which are being worked. Place the cards at intervals around the pool side (shallow end) and split your mothers into as many groups as you have cards. Ask them to follow the instructions on each card before moving on to the next. Intersperse with some low intensity aerobic activity, such as gentle jogging across the width of the pool to maintain warmth.

The “rubber duckathon” A great revitaliser which adds a little competitive fun! Split the group into two teams and direct them to create a circle with their woggles (connectors are useful here) by holding the end of each other’s woggle. Tell the teams that their mission, should they choose to accept it, requires them to rescue ducks from one side of the pool within their circular woggle “nest” and to transport them individually, without using their hands, to the other side of the pool (a plastic container is useful to store the ducks). To add interest, the ducks can be individually decorated with baby names which can be changed regularly by the mothers themselves. This also helps mothers to consider names for their child.

“New York basket ball” Great fun for the aerobic component or as a revitaliser. For this you will need some small plastic balls, several plastic buckets and a wedge of some sort to place the bucket at the edge of the pool side angled towards the water edge. Everyone is invited to throw the balls into the bucket and when they succeed they can exit the pool as their reward. As some people will invariably miss, it might require some mothers to stand nearer to the buckets but as it takes quite a bit of concentration it is an ideal strategy to bring them back to a refreshed state before exiting the pool.

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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals These are only a small selection of our ideas; there are many more and we are confident that with time your repertoire will grow!

To summarise ● Routines are important from a safety point of view but so too is creativity. ● A good aquanatal coach will maintain a balance between safe routines and creative ideas. ● With time and effort and as coaching confidence grows, a vast repertoire of exercises and games can be created.

Our tips

u can. o y s a s soon a s ts e c all gif sour e m r . s f e o t a ry to don a libra s p e u i c g en din her ag r rt buil t a o t d S n a sed fo ● s u e . f u s l i g e a t e rs k coll k wha l on a s you l s t a a f b i t g d e n ● As g n a in plastic ing plastic er mak r pool d u i a o s , y n e l o s ● C around – for examp you u k e v o a o s l l l s ve a d it wi ession y! n s a ● Ha e y a s l e p activit h t l s l ’ e a n v b e a r h et child pools k bask t r s o o Y M w stand. the Ne r o f ts bucke

Useful Sources of Information Water Fun Book and 52-minute DVD available from www.humankinetics.com/swimming (accessed 19.10.09) www.twenga.co.uk for a wide selection of buoyancy aids (accessed 19.10.09) www.gbsports.co.uk for woggle (noodle) connectors (accessed 19.10.09)


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Chapter 7 Contra-indicated aquanatal exercises Any physical exercise has the potential to create injury if either inappropriately selected or if not practised correctly. Therefore, in order to minimise risk, the aquanatal coach needs to understand not only the individual characteristics of her target group but also the individual characteristics of the exercise being taught. A thorough knowledge of pregnancy physiology combined with knowledge of exercise physiology is essential. The following list is generated from the most recent professional guidance (American College of Obstetrics and Gynaecology 2002 ).

Avoid the inclusion of: ● Lengthy aerobic exercise routines, especially during the first and third trimester. Initial hormonal changes can induce tiredness and fatigue, and later the weight of the growing uterus and the effects of extra weight distribution can result in the mother experiencing breathlessness and extreme tiredness. ● Competitive exercise should always be avoided, due to the increased risk of maternal injury as a result of general joint instability during pregnancy. ● Lengthy and vigorous stretches can compound already unstable joints and lead to long term morbidity. ● Foot exercises that require the toes to be pointed excessively can lead to cramp and pain whilst in the water. ● Excessively speedy directional changes whilst in the water can result in muscular injury. Working against inertia requires abdominal fixation and the abdominal muscles during pregnancy already have to support the growing uterus. Any sudden and extra stress could result in round ligament pain. ● Hyperextension of the neck could cause injury to the cervical spine, a subsequent loss of balance, pain and discomfort. ● Exercises with the knees locked (straight legs) such as toe touching and long kicks can lead to the hip flexor muscles which are attached to the lumbar vertebrae becoming shortened in pregnancy. They are already under great strain from the effects of the growing uterus and exacerbation may lead to long term lower back pain and increased lumbar lordosis. ● Avoid fixed (locked knees) when performing exercises generally. ● Excessive rebound moves, whilst not really a problem in the first trimester if considered individually, can become so in the subsequent trimesters due to over stretching of the pelvic floor, pelvic and hip joints. ● “Power adduction” exercises (taking wide steps laterally) can lead to the adductor muscles becoming stressed and diastases of the pubis can result. ● Twisting the torso generally works the oblique muscles which attach to the aponeurosis. This muscle is greatly stretched already in pregnancy and injury can result due to inappropriate and sudden movement.


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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals ● Too many repetitions of one particular exercise may cause one set of muscles to become overworked at the expense of others needing to be exercised. ● Avoid abdominal work after the 34th week of pregnancy – for example “curl ups” when floating on the surface of the water. The abdominal sheath can be injured as a result and some mothers could experience acid reflux due to compression. ● Avoid too many isometric contractions (static muscular contractions); the muscles need to generate force and then need to attempt to shorten, but cannot overcome external resistance. An example of this is when holding a position against the effects of gravity when in air and a resistor (such as a flotation aid) when in water. ● Any exercise where a bent knee is required, but the knee is not checked to be positioned anatomically over the foot. This can lead to lower leg and back injury. ● Exercises which require large dramatic movements can create the potential for injury. Avoid plymetric jumps, as the joints are already unstable due to the pregnancy hormones. Also, the pregnant uterus is totally unsupported when the body jumps out of the water. ● When using a flotation aid for relaxation, you need to tell mothers to avoid leaning forward onto their abdominals, as this increases lumbar lordosis and can result in long term morbidity. ● Avoid any exercise which involves the neck, as there is great potential for injuring the cervical spine and we have no way of actually screening the health of an individual’s neck. ● Avoid wall press and pull ups as the head, face and teeth can be injured against the tiles. ● Avoid over correcting posture during pregnancy; it used to be advised but now it is recognised as causing too much stress on the lower abdominals, which already have to stretch in order to support the growing uterus. ● Avoid “star jumps”. These exercises can cause over-adduction of the legs and they also have the potential to be practised plymetrically and result in further injury. ● When performing a quadriceps stretch avoid holding on to the ankle, as the muscle (rectus femoris) can become over-stretched due to the hormonal responses of pregnancy. Whilst this list may seem daunting at first, it will ultimately become clearer once you have become more familiar with some basic aquanatal exercises. It is suggested that as a new aquanatal coach you adhere to the “KISS” principle: Keep your exercise routines Simple and therefore Safe. NB: Deep squatting is contra-indicated when exercising on dry land during pregnancy, but is considered safe when exercising under guidance in water. There are plenty of exercises that are safe for you to include in your sessions!

References American College of Obstetricians and Gynecologists (2002) ACOG Committee, Opinion no: 267: Exercise during pregnancy and the post partum period. Obstetrics and Gynaecology 99: 171–173.


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Chapter 8 The pelvic floor and aquanatal exercise This chapter aims to create awareness of the importance of pelvic floor health within the female population, and consider the value of physical and aquatic exercise programmes for achieving and maintaining pelvic floor integrity. (We also offer specific water based exercise and tips in Chapters 4–6.)

Firstly a definition of the female pelvic floor:

“The pelvic floor is primarily composed of soft tissues which fill the outlet of the pelvis. The most important of these is the funnel-shaped diaphragm of muscle attached to the pelvic walls.The posterior part of the diaphragm of muscles lies higher than the anterior. Through it passes the urethra, vagina and anal canal” (Stables and Rankin 2005, p339).

Figure 8.1 Side view of pelvic floor anatomy

Next, a definition of urinary incontinence:

“Involuntary urine loss that is objectively shown and a social and hygiene problem” (Abrams, Blaivas, Stanton and Anderson 1988, p 403)


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Why we need a pelvic floor: ● ● ● ● ● ● ● ● ●

In order to cough In order to sneeze In order to vomit In order to have sexual intercourse In order to urinate In order to aid defecation In order to lift In order to walk and run In order to give birth vaginally

Over the past ten years or so, there has been increasing interest in how pregnancy and childbirth impact upon the health of the pelvic floor and additionally how pelvic floor health impacts on a woman’s physical and psychological well-being – her quality of life. Chaliha, Sulton and Stanton (1999) reported that this interest was due to two factors, a decline in UK maternal mortality and a rise in female life expectancy, which in the nineties was recorded as 80 years of age. Latest figures also support this trend by showing the rise to be 81 years (Office for National Statistics 2006). Mary O’Dwyer (2007) an Australian physiotherapist and pelvic floor exercise expert, reports that the current interest in the “epidemic of pelvic floor dysfunction” confirms it to be generally accepted by women as part of being female and having babies. She offers that women hear about their own mothers’ pelvic floor problems, but do not seek out ways to prevent it happening to themselves; instead they continue to suffer silently. She moves on, however, to examine the impact it has on women’s quality of life and ultimately their well being, by referring to the pelvic floor as the “pelvic flaw” – the title of her book. Women, when they eventually do break their silence and seek help, generally do so due to their symptoms becoming “bothersome” or socially disabling. We can see from these descriptions that they range from the minor to the severe. Ann Walsh, a lecturer in midwifery and psychology, states that women demonstrate varying degrees of psychological ill health due to the severity of their symptoms, including personal distress, continual embarrassment due to their incontinence and fear of having a body odour, and a loss of personal control, due to having to plan their activities around the nearest toilet facilities. She says that due to these factors, many women demonstrate low self esteem and desire just to be normal (Walsh 2008). Women are still in the main ignorant about the causes and prevention of pelvic floor dysfunction. If we ask a laywoman to tell us about her pelvic floor, it is likely that she will not even be able to describe where it is, let alone why or how she should be exercising it. This is also applicable to men, as few articulate their knowledge of actually having one! Pelvic floor integrity is important, not only to a woman’s quality of life, but also to NHS finite financial resources. In 2000, Thaker and Stanton estimated the diagnosis, treatment and further management of urinary incontinence cost the NHS around £424 million per annum and this was thought to be a conservative estimate. It was found to be more than the amount apportioned to the entire diabetes mellitus budget. It is estimated currently that in excess of 3 million adults are regularly incontinent in the UK. Of these it is thought the vast majority are women and a third are women over the age of 40 years (The Continence Foundation). Further, information provided by the National Childbirth Trust (NCT) reports that, of the 669,601 babies born in the UK in 2007, only 25,000 mothers attended any formal parent education or maternity exercise class to learn how to perform appropriate pelvic floor exercises (The Times 2008). The figures offer some insight into the nature and probable extent of this problem. In order to protect their


The pelvic floor and aquanatal exercise pelvic floor muscles in both the short and long term from the extra abdominal weight placed upon them during pregnancy, mothers need to be encouraged to access timely and appropriate information. It is interesting to learn that women who experience stress incontinence during their first pregnancy are at 50% greater risk of further incontinence problems for up to 15 years, even if their initial symptoms are seemingly resolved postnatally (Dolan et al 2003). It is no surprise then, to learn that if a woman becomes pregnant in her twenties she could still have or subsequently develop urinary stress related symptoms well into her forties. This seems to support the current evidence which infers that most women experience greater symptoms within this age group (The Continence Foundation 2008). Muscular integrity tends to generally degenerate with age and this process is heightened in those muscles which have previously been injured. Perhaps we can refer to this as “muscle with a memory” in the same way we refer to uterine muscle action in labour.

Other factors which contribute to poor pelvic floor integrity: ● ● ● ● ● ●

Delaying emptying the bladder Regularly stopping the stream of urine when emptying the bladder Constipation – straining to empty the lower bowel Obesity > BMI prior to pregnancy and excessive weight gain during pregnancy. Slouching when sitting – creating pressure on the lower abdomen and thus the pelvic floor “Hovering” over the toilet – when not wishing to sit on a toilet seat – this creates pressure on the pelvic floor from the abdomen. This is not a problem in cultures where squatting is practised to pass urine, as the pelvis is then much lower and better supported by the lower body generally. ● Lifting heavy loads ● Incorrect coughing – (perhaps due to smoking cigarettes) not supporting the abdominal muscles ● Poor sexual health and hygiene – resulting in recurrent urinary tract infections (UTIs) which can lead to pressure on the pelvic floor when repeatedly having to pass urine, and straining to void urine when the bladder does not need emptying. (Sharma et al, 2009)

O’Dwyer (2007) also includes: ● Doing pelvic floor exercise at the traffic lights – meaning when sitting in a car seat and being stressed. ● Doing sit ups and pelvic crunches and bilateral leg raises from the floor ● Engaging in sustained tightening of the waist line (holding in the abdomen); this directs the pressure to the lower abdominals and thus on to the pelvic floor. ● Thinking that an elective Caesarean section, rather than a spontaneous vaginal birth, will protect the pelvic floor from damage – the evidence suggests there is little difference between the two and this highlights damage being due to increased abdominal weight and pressure on the pelvic floor. However, there is much evidence to suggest that inappropriate medically assisted vaginal births can increase the risk of both perineal and pelvic floor trauma – thus an iatrogenic causation? (Fernando and Sultan 2004; Sullivan and Hayman 2008).

It may be useful to refer women who have had a Caesarean section to an obstetric physiotherapist for postnatal pelvic floor exercises, as well as chest physiotherapy. The abdominal muscles have been incised. Anything that weakens the lower abdominal muscles must surely increase the pressure on the pelvic floor.

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Pelvic floor exercises Appropriate exercising of the pelvic floor muscles is an important strategy to avoid long term morbidity and poor quality of life. The Kegel method, developed by the doctor of this name in 1946, is today still generally accepted by health professionals as the gold standard exercise routine for maintaining pelvic floor health. It focuses on strengthening the pubococcygeous muscles (PC) which make up the major muscles of the pelvic floor. These are found to be excessively relaxed or stretched in women presenting with the symptoms of stress incontinence. Whilst this method is professionally accepted, there is some debate regarding whether it is of benefit purely on its own when dealing with genuine stress incontinence or whether the added use of vaginal and weighted cones, to provide resistance, is more beneficial. Cammu (2005) compared women who used such resistors to those who did not when performing Kegel exercises. He concluded that there were no significant differences between the control and the active research group, in terms of improved outcome, and suggested that his findings were associated with poor uptake and compliance with pelvic floor exercise generally, rather than the added use of resistors specifically. He therefore did not see the need for resistance tools, rather seeing the need to improve uptake and compliance with Kegel exercises throughout the woman’s life generally. As no empirical evidence exists regarding when the exercises should either start or end, we need to be recommending that all women from menarche to the menopause (and beyond!) practise them. We also need to be telling women and especially those who are pregnant, to practice between eight and twelve contractions, three times daily, ensuring they follow the correct technique of slow pulsations and fast twitches in order to exercise both types of pelvic floor muscle fibres. For example, three slow, holding each for three seconds then five fast (International Consultations on Incontinence, Ghoniem et al 2005, and NICE recommendations 2006).

The problems associated with deck exercises during pregnancy Hopefully we have highlighted the need for women to exercise their pelvic floor muscles and the benefits of the Kegel method for doing so. Referring back to O’Dwyer’s words regarding the need to avoid sit ups, pelvic crunches and bilateral leg raises from the floor, it can immediately be seen that some or all of these are often included in dry land exercise routines (deck exercises). If women were to attend these types of classes during pregnancy they would probably find they were the norm. Deck exercises are also general in design, to account for a wide variety of women attending. If a woman was to begin such a class when pregnant and not used to physical activity, she could potentially put herself and her unborn baby at risk. These classes are conducted in unchecked ambient temperatures, more likely than not. Groups can be large, music too loud and visibility of the instructor impaired. The emphasis is generally placed upon social fun. This can lead to the pregnant woman experiencing a whole host of problems including hyperthermia, due to too quick a pace, trying to keep up, too stuffy an atmosphere, sweating and then becoming dehydrated. Additionally, she could incur joint injury due to practising inappropriate exercises. She could faint from lying prone on the floor and become over-exerted generally, which could alter the transference of maternal glucose from supplying the placenta for the respiratory needs of the foetus to it being required for her own increased muscular energy requirements. Further, if she did pelvic floor exercises, they would not be designed to take account of the extra abdominal weight she was carrying and the effects of gravity would add to her pressure symptoms. All in all the scenario is a worrying one and unfortunately the only way she would know that she was overdoing it, would be when visiting the toilet following the class and finding that her urine was probably more concentrated, and that it was “hot”, a sure sign that her core body temperature was too high. A potential consequence could be increased risk of foetal morbidity.


The pelvic floor and aquanatal exercise

The benefits of water based aquanatal exercise during pregnancy If planned, facilitated and evaluated competently, aquanatal exercise can provide the mother with a holistic body work-out. All the major joints and muscle groups can be exercised through their full range of movement. Importantly, the mother’s individual circumstances can be taken into account from the very first session by completing a written questionnaire in addition to the subsequent weekly visual and verbal checks. Utilising the benefits of buoyancy and hydrostatic pressure, the exercises can be made to be far more effective, and also far safer (see Chapter 1). Due to the effects of buoyancy, pressure is alleviated from the lower body and as a consequence the mother can more effectively exercise the muscles of the pelvic floor without the added risk of causing injury due to the weight of the gravid uterus within the abdomen. It is generally accepted that buoyancy decreases the pressure on the lower body and its joints by between 50 and 80% (Baum 1998) Also, as the water environment is twelve times more resistant than air and therefore is a more difficult medium to work in, exercise repetitions and duration of session time can be reduced whilst still achieving the same effect as that on dry land in terms of calorific expenditure and muscular development. Another important factor when exercising the pelvic floor in water and in making the exercises more effective is that of having an empty bladder. All mothers are encouraged to go to the toilet before entering the pool and also to leave the pool at any time to empty their bladder as they feel is necessary. The hydrostatic pressure of the water leads ultimately to improved diuresis and bladder emptying and also renal stability, so enabling the mother to maintain appropriate systemic fluid levels for the duration of the session, with less likelihood of becoming de-hydrated and thus enabling a more effective muscular work-out. When exercising the pelvic floor in water, the mother can make use of floatation aids such as noodles (woggles) to create interest and aid support, it is also easier for both parties to check visually that the gluteus muscles are not being squeezed together when performing the exercises! The pool environment is ideal for displaying visual props on the pool side, such as pictures of the pelvic floor. Also, plastic or rubber pelvises can be used by the coach, whilst in the water, to add interest and provide specific coaching tips. The music can be lowered and used to provide the relaxed approach required. For examples of specific pelvic floor exercises see Chapter 4. Finally, by exercising the pelvic floor as part of a small group in the privacy of the pool environment, women can be introduced to the correct terminology in a private and sensitive manner to avoid embarrassment. The midwife/coach can also introduce public health information such as that relating to the pelvic floor health of their partner. When considering the male, for example, current evidence suggests that regular pelvic floor exercise will aid blood flow to the pelvic organs, impact upon the effective functioning in later life of the prostate gland and also that it may reduce the incidence of impotency caused by erectile dysfunction (Dorey 2003). The aquanatal coach is therefore providing a valuable public health role and addressing the wider health of the community.

To summarise ● The health of the pelvic floor is a concern for both men and women. ● Urinary stress incontinence affects the woman’s well being and the quality of her life. ● Diagnosis, treatment and long term management of female urinary stress incontinence can impact greatly on finite NHS Budgets.

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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals ● The condition is very often a silent one due to personal embarrassment and social stigma. ● The condition is linked to childbirth, weight, weight management and obesity. ● Dry land (deck) exercise environments are not the most appropriate for exercising the pelvic floor muscles during pregnancy. ● Aquanatal exercise provides an ideal environment for exercising the pelvic floor muscles.

Our tips

your n i s e c rvi this is nce se ; e d n i a t e l n o l ss inc ssiona t in the e e r f t o s r p y urinar rimary interes p h l a c d i r e c a e e m p s na ● Re ith a s e resource. have a w t t s s i o m from luabl herap y a t p v o i o area – a s c y a is ly a ph erson an get p c s u i o usual h T .11.09). , y . k 17 r o o d o o e b l s f acces ublic pelvic wyer’s t p D ’ s r a O l e ( h y u rt ad Mar .com.a for fu r o me and 9). m o o l u ● Re r f h o c i e f v k l ta 11.0 th mype rs to s heal sed 18. e ’ s n h e www. e t c o m c he c your m o.uk (last a r o cess t f a Pelvi c A n e c t . o i e l t m ● a p u or inform to com her ealthf s h r s e n h e health t mo furt w.m t w w e e g w n ed n ! r a you u c ccess share o g a Y n i t . k to s a s a l m a eated uk ( -for . r o o c r nsider c p . y o t n C i t ar co en ● nal ch sessm www.promo o s i t A a n r s is, Floo ered om s t r e r f s i d g n d e a o r a ati . Their gland, n s inform romoCon is E s e n A e other Q r 8 a d P n w 8 . a a ) M 9 s e , t 18.11.0 . ntinenc Manchester rious leafle o c e ssues i t , a o e t v c m e n t e o e ge tr pr contin ad’s S u can f h o o Y C o . . s 4 t 459 4 S video diary t 14 e r 2 n i o 1 l o n 16 l o on for f 0 i t : h c a e i v c v n i t l t o a e o p w Ph m ther a rease es and o c c n r m i u y o o r t e res iving ev d help l g u r o e o d c i ns hem t This t . y e l ● Co t k a e n i ete we ises! and lam r o o compl l c r f he exe pelvic t e g home. h n t i e o k f d a o t o ures pool. hers t t e o t pict h e t m G t r a o ● d use aflet f n e a l y n a o l i t disp forma n i n a vise ● De


The pelvic floor and aquanatal exercise

References Abrams, P.H., Blaivas, J.G., Stanton, S.L. and Anderson, J.T. (1988) Standardization of terminology of the lower urinary tract function. Journal of Neurourology and Urodynamics (7):403–427. Baum, G. (1998) Aquarobics: The training manual. London: Harcourt. Button, D., Roe, B., Webb, C., Frith, T., Colin, Thome, D. and Gardner, L. (1998) Continence Promotion and Management by the Primary Health Care Team: Consensus Guidelines. London: Whurr Publishers. Cammu (2005) cited in: Bø, K., Kvarstein, B., Nygaard, I.(2005) Lower urinary tract symptoms and pelvic floor muscle adherence after 15 years. Obstetrics and Gynaecology 105 (5) part 1: 999–1005. Chaliha, C., Sulton, A.H. and Stanton, S.L. (1999) Changes in the pelvic floor following childbirth. Fetal and Maternal Medicine Review 11: 41–54. Dolan, L. M., Hosker, G. L., Mallett, V. T., Allen, R. E. and Smith, A.R.B. (2003) Stress incontinence and pelvic floor neurophysiology 15 years after the first delivery. The Warrell Unit, Saint Mary’s Hospital, Manchester, UK. Copyright RCOG 2003. BJOG: an International Journal of Obstetrics and Gynaecology. Dorey, G. (2003) Male Impotence and Pelvic Floor Exercise. University of the West of England, Bristol. www.NetDoctor.co.uk (last accessed 04.01.10). Fernando, A. and Sultan, A. (2004) Risk factors and management of obstetric perineal injury. Current obstetrics and gynaecology 14 (5): 320–326. Ghoniem, G., Van Leeuwen, J., Elser, D., Freeman, R., Zhao, Y., Yalcin, I. and Bump, R. (2005) A randomized controlled trial of duloxetine alone, pelvic floor muscle training alone, combined treatment and no active treatment in women with stress urinary incontinence. The Journal of Urology 173 (5): 1647–1653. National Childbirth Trust (2007) Reported in The Times newspaper online 25 January 2008 www.timesonline.co.uk (last accessed 17.11.09). National Institute for Health and Clinical Excellence (2006) Urinary Incontinence: The Management of Urinary Incontinence in Women October 2006: CG40 www.nice.org (accessed 17.11.09). O’ Dwyer, M. (2007) My Pelvic Flaw (published in Australia) obtained from www.mypelvicflaw.com.au (accessed 17.11.09). Office for National Statistics (2006) Office of National Statistics: Life expectancy London www.statistics.gov.uk/hub/release-calendar/index.html (last accessed 18.12.09). Sharma, J.B., Aggarwal, S., Singhal, S., Kumarand, S.and Roy, K.K. (2009) Prevalence of urinary incontinence and other urological problems during pregnancy: a questionnaire based study. Archives of Gynecology and Obstetrics 279 (6): June. Stables, D. and Rankin, J. (2005) Physiology in Childbearing. London: Elsevier Harcourt. Sullivan, C. and Hayman, R. (2008) Instrumental vaginal delivery. Obstetrics, Gynaecology and Reproductive Medicine 18 (4) April 99–105. Thaker, R. and Stanton, S. (2000) Management of Urinary Incontinence in women. British Medical Journal 25 November 321: 1326–1331. The Continence Foundation (2008) www.continence-foundation.org.uk (accessed 18.11.09). Walsh, A. (2008) The Psychology of Female Urinary Stress Incontinence. Presented to Students on the Pregnancy Aquatics, Nutrition and Health Module, February 2008. University of Salford, UK.

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Part 2

Aquanatal exercise the wider context



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Chapter 9 Ethical considerations “Let me give you the definition of ethics: it is good to maintain life and to further life. It is bad to damage and destroy life. And this ethic, profound and universal, has the significance of a religion. It is religion.” Albert Schweitzer (as quoted in Albert Schweitzer: the Man and his Mind (1947) by George Seaver p 366. www.wikiquote.org)

The aim of this chapter is to consider why knowledge of ethics is fundamental to midwives practising as aquanatal coaches. As midwives, ethics are threaded through our professional training, as we refer to the mother as an individual and to the nature of holistic care. We are therefore assuming the mother to have a moral position based upon her own set of values which influence the choices she makes whilst receiving care (Downie and Calman 1994). In so doing we assume a professional relationship with her, based very much on supporting her autonomy, whilst simultaneously attempting to demonstrate ours. For the relationship to be considered moral, it needs to be equitable with a mutual balance of power within it. Our professional relationships are most effective when we can engage in activities with mothers which enable this to happen. It is, however, difficult to achieve at times, as we practise against a backdrop of increasing medicalisation, which can lead to fragmented care and the midwife being replaced by technology. Isaacs and Massey (1994) refer to the construction of a meaningful midwife–mother relationship, which is based upon engaging, being with and recognising maternal individuality. When at a swimming pool and engaging with mothers, the midwife is with the woman both initially on the pool side and then later in the water and is educated in the skills necessary to create an individual experience. As midwives, being professional means working to an ethical code of acceptable and professional behaviour in order to do good and prevent harm (NMC 2004). Such an ethical code may value the artistic creativity of midwifery. Midwives who choose to facilitate aquanatal exercise sessions are demonstrating that art.

The ethics relating to the provision of physical exercise or “how to behave and what you ought to do” There are four main ethical principles (normative) which are relevant to health and social care: ● Respect for autonomy ● Non-maleficence (doing no harm) ● Beneficence (doing good to another person) ● Justice (fairness) These moral principles provide us with the tools to enable identification and reflection on the issues relating


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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals to our practice and to how we should aspire to behave. Beauchamp and Childress (2001) suggest that there is often conflict within health and social care provision due to the practitioners trying to do good at the expense of negating the individual’s autonomy and therefore creating professional paternalism. We therefore need to ensure that in order to do good the action needs to be perceived as valuable to the individual mother and that her right to choose it autonomously is supported. The principle of non-maleficence is defined as “Primum non nocere” – above all do no harm (Singer 2000). It very often goes hand in hand with the principle of beneficence. By benefiting others you are not causing them injury. Harm resulting from water based exercise in pregnancy can create immediate or acute injury or result in chronic morbidity. Perpetrators of this type of harm are usually those exercise professionals who have not undertaken appropriate training, have not maintained their professional currency and therefore capability, or have not adhered to their code of ethical conduct. We often refer within midwifery to a duty of care and this is derived from the legal description of not demonstrating due care and attention (Dimond 2006), usually as a result of negligence. This duty of care follows us into our aquanatal exercise coaching roles and we need to acknowledge it (see Chapter 13 The law and aquanatal exercise). Finally, justice is entirely relevant within programmes of aquanatal exercise as we need to apportion equality to all our mothers. Consider, for example, a woman choosing to attend your aquanatal session; what might her needs be? Physical needs may be: to moderate her exercise routine whilst pregnant; to begin to exercise safely during pregnancy in order to improve her fitness; to alleviate the symptoms of a debilitating illness such as multiple sclerosis; to engage in a normal activity if she is suffering from a disability; to address a pregnancy acquired disorder such as symphysis pubis dysfunction. Psychosocial needs may be: to meet and interact with other mums and forge relationships; to obtain peer support; to be part of a like minded group; to reduce the likelihood of becoming depressed; to have a break from the demands of daily life. Emotional/ behavioural needs: to alleviate stress; to increase self esteem; to gain birthing confidence; to feel better within themselves; to improve sleep. Educational needs: to receive continuity from a known midwife; to obtain pregnancy information; to become aware of other services they might choose to engage with; to have their pregnancy health concerns dealt with; or they might attend simply to try it out! When facilitating a class, we are required to try to meet all these needs and probably more. How are you going to do this? According to Boone (2008) if you are practising ethically and therefore morally, you need to first consider yourself and ask the following questions: ● Why am I offering aquanatal exercise classes (for my own or for the benefit of mothers)? ● How does it define me personally? ● What is my purpose in life? ● How will I know when I am happy and mothers attending are happy? You might consider the value of completing a pre- and post-session self assessment. This is often in the form of an evaluation, but here we suggest additionally that you also consider your feelings. This allows you to focus on the quality of the sessions you are providing by addressing any issues promptly. It also allows you to ensure that as far as reasonably possible you meet the individual needs of the group by considering their feedback. (See pre- and post-session self assessment table at end of chapter.) Further points for consideration include: confidentiality, veracity (telling the truth) and fidelity (loyalty). Maintaining confidentiality is an important feature of every professional code and aquanatal exercise is no exception. Throughout the exercise industry, each major awarding body will have its own code of professional ethical practice and upon successfully gaining an award each exercise coach will need to work within that code.


Ethical considerations We need to remember, however, that some leisure industry employers might also have devised their own ethical codes and whilst there will be great similarities, there will also invariably be some minor differences. It is therefore up to the individual coach to work within the code relating to their contract of employment, and specially so if working for several different employers, as can be the case within this industry. They will need to become familiar with each one and modify their practice accordingly (ASA 2003). The British Institute of Sports Coaches (BISC) published their Code of Ethics in 1989. The National Coaching Foundation further developed it by also including the principles contained within the Council of Europe’s Code of Sports Ethics. This code now forms the value statement underpinning the National Vocational Qualification Standards (1992) for Coaching, Teaching and Instructing, and replaced the BISC code in the 1998 revised standards. The code is seen as a series of guidelines to guide professional behaviour and set standards, rather than a prescriptive set of instructions. All sports coaches, of whatever discipline, need to aspire to these standards in a number of areas: ● Developing a professional relationship ● Demonstrating humanity ● Demonstrating commitment ● Demonstrating co-operation ● Demonstrating integrity and non–affiliation with specific companies. ● Maintaining client confidentiality ● Demonstrating that they are not abusing their position of trust ● Maintaining client safety and also the safety of their team ● Ensuring professional competency. More specifically to aquanatal exercise, the United Kingdom (UK) Register of Exercise Professionals (REP) published its own Code of Ethical Practice in January 2005. The register was originally set up to create national exercise standards in order to protect the public. It set about doing this by introducing a process of rigorous self-regulation for all instructors, coaches, trainers and teachers involved in supervising people who partake in physical activity programmes. It has subsequently created the National Standard for professional exercise quality. There are many criteria that the REP requires each exercise professional to satisfy, initially and then annually, ranging from gaining a recognised and approved exercise qualification to adhering to its professional ethical code of conduct. Therefore it would be appropriate for you to have accessed a course of aquanatal exercise training which is approved by the register. The REP has devised a statement of intent (mission statement) to advertise its aims:“To ensure that all exercise professionals are suitably knowledgeable and qualified to help safeguard and to promote the health and interests of the people who use their services” (REP 2005, p2). We need to devise our own mission statement when working as independent aquanatal coaches or ideally it should be a part of a team one, when employed by the leisure service industry. You may find it useful to consider the following true examples. Each requires thought, moral consideration and appropriate action on your part: ● The partner of one of the mothers attending your aquanatal session arrives on the pool side as the session begins and starts to film the session with his camcorder. What principles are being breached and what could be the possible outcomes? What might you do? ● A woman from a different cultural/religious background arrives at your session for the first time – she asks if the lifeguard is female. She explains that within her culture it is deemed inappropriate for a male to see her partially clothed. She is extremely anxious and indicates that she will not be able to join the session if the lifeguard is male, but she is also very keen to begin aquanatal exercise. If you are practising ethically, to whom and what are your responsibilities? What might you do?

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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals ● A physically disabled mother (above-knee, left leg amputation) arrives at your session for the first time. She explains that it has taken her a long time to pluck up the courage to attend. She is with her sister, who will accompany her into the water. What, if any, are the issues here? What do you need to consider? How can you balance the needs of the mother with the needs of the whole group? What might you do?

“Do all the good you can, by all the means you can, in all the ways you can, in all the places you can, at all the times you can, to all the people you can, as long as ever you can”. John Wesley (www.wikiquote.org)

To summarise ● Normative or practical ethics provide us with a framework of principles for how best to practise. ● There is a need professionally to develop ethical relationships with others which are based on equity of both parties. ● Values, needs and rights impact upon our own behaviour and the ethical behaviour of others. ● Self-reflection can help decision making about ethical practice. ● All professional exercise coaches are required to adhere to ethical codes of practice in order to safeguard the general public.

Our tips

vise a e d , ne s everyo ssion e o s t n s w d your o our standar h your c l a l a o y c r e o f at to munic arting erhead t t m s t o e c l n e a h to f ● W sed as ement u t a e on sel t i b s s s o n e s o i s l a miss d post ence. is can n d s. h a n T o . e p d r s p e feeling r a r d o g n n a c i involve t d e ts compl sing an hough i t f t r o r e u v t i d o a first y e y hab r d e e u v l h t c n he t into sional a and i y on t s r m e a r f t o o n ● Ge f r e pro ur p omm ear of o n y c y o i a e t n v i a i r t e u it t c eval . Keep aps af nd a refle r h e e r f k e f a p t o , a u der . Later r one e ion yo o ● Un i l s h t s o ! e o f t n s tal hanged ete a l c r) por p e e h v m t a o aquana o h c r w you sions, ery (o o s f i e h s w t d g i a f your ur M d rin o e e z f e a f n m o o a o n rly k on y it in o will be c s regula a u b o d o t e y n your re – ague o th fe a e i l p k l w c o m a c o u c e r db yo nd ton th fee riend o and provide i a f , w t a c u k a t yo ● As ye con u may rovide ssions e e o p , Y s s o . l t s a s e t o n m riendli nneris aquana nce but als a f m g n i d d n ma s a clu l skill perfor ty traits, in a b r e v tion. a , i l e c i a g n n a o u u g m n pers ody la er com b t , t e e b c i of vo effect o t n a l then p


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Ethical considerations

Our tips

Discuss the issue of profes pool staf f managem sional exe rcise eth ent and c address c ics with olleagues ertain situ ; ask how a t io n s they wou . ● As y ld our relatio n s h ip the benef grows wit its of pro h pool st f essional r aff, sugge be mainly e st flection ( a health s a s this se ervice and Suggest t e ms to nursing/m o managem idwifery a ent that t reflective ctivity). hey consid tool with er utilisin in the leis order to im g a ure servic pact on s e environm ervice qua ent in lity. ●

References Amateur Swimming Association (2003) Guidance Booklet for the management and delivery of teaching and coaching of swimming. London: ASA. Beauchamp, T.L. & Childress, J.F. (2001) Principles of Biomedical Ethics. 5th edition. Oxford: Oxford University Press. Boone, T. (2008) Exercise as Medicine. Professionalization of Exercise Physiology online 11(2) February 2008. faculty.css.edu/tboone2/asep/JPEP.html (accessed 12.11.09). British Institute of Sports Coaches (1989) www.brianmac.co.uk (last accessed 18.12.09). Dimond, B. (2006) Legal Aspects of Midwifery. 3rd edition. Edinburgh: Elsevier Butterworth Heinemann Books for Midwives. Department of Health (2007) Maternity Matters; Choice, Access and Continuity of Care in a safe service. London: DH. Downie, R.S. and Calman, K.C. (1994) Healthy Respect: ethics in health care. Oxford: Oxford Medical Publications. Human Rights Act (1998) Schedule 1 the Articles of the European Convention on Human Rights. Part 1 Article 1. Geneva / London: Crown Copyright. Human Rights Act (1998) Schedule 1 the Articles of the European Convention on Human Rights. Part 1 Article 8. Geneva / London: Crown Copyright. Isaacs, P. and Massey, D. (1994) Mapping the Applied Ethics Agenda. Paper presented at the Third Annual meeting of the Australian Association for Practical and Professional Ethics. Sydney. Kant, E. (1724–1804) In Norman, R. (1998) The Moral Philosophies. Oxford: Oxford University Press. National Vocational Qualification Standards (1992) for Coaching, Teaching and Instructing. www.brianmac.co.uk (last accessed 18.12.09). Nursing and Midwifery Council (2004) Midwives’ rules and standards. London: NMC. Register of Exercise Professionals (2005) Code of Ethical Practice. London: Register of Exercise Professionals. Singer, P. (2000) A Companion to Ethics. Oxford: Blackwell. Woodford, H. and Munns, G. (2003) Paper presented at the New Zealand Association for Research in Education (NZARE) & The Australian Association for Research in Education (AARE). Auckland: Australia.

Useful sources of information/contacts Aquatic Exercise Association (AEA) www.aeawave.com (last accessed 23.02.09). Aquatic Guidelines – ACPWH Leaflet Secretary, c/o csp 14 Bedford Row, London WC1 4ED Tel: 020 7306 6666. Awarding bodies – Central YMCA, Qualifications, 111 Great Russell Street, London WD3 3BR Tel: 020 7343 1850. Amateur Swimming Association (ASA) Education Department, 18 Derby Square, Loughborough LE11 5AL Tel: 01509 618 722.


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Pre- and Post-Session Self Assessment modified from “SOLO” TAXONOMY (Woodward and Munns 2003

Affective

Cognition

(feelings)

(intellectual awareness)

Operation

Comments

How am I feeling at the moment?

What are my aims for this session?

Did I achieve my aims? If not, why not?

What else could I have done?

Why am I feeling this way?

Have I met all practice requirements?

Did the mothers evaluate the session positively? If not, why not?

Do I need to develop my practice?

What effects might my feelings have on the quality of my session?

How am I presenting myself?

What went well and why?

What do I need to change for the future?

What body language will I be conveying as a result?

Have I welcomed and screened all mothers?

What did not go so well and why?

How do I feel now?


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Chapter 10 Public health, physical activity and aquanatal exercise “It is the duty of every person to take care of the body and develop it as well as the mind” (William Wood, 1867, Manual of Physical Exercises. New York: Harper & Brothers)

This chapter aims to briefly review the progression of public health within the United Kingdom (UK) before considering the value of physical exercise and pregnancy aquatics to health and well being. “Public health is the science and the art of preventing disease, prolonging life and promoting health through the organised efforts of society” (Acheson 1988). However, it is recognised that the most influential factor in determining how healthy each one of us is, and the quality of healthcare we receive, seems to be the actual social group we belong to. In 1997, the then Labour government created “Health Action Zones” (HAZ). Twenty-six were initially set up in areas throughout the country identified as being most socially compromised. Over a seven-year period, the pilot study aimed to explore strategies for breaking down those social barriers which impacted negatively on health and well being, and also to create opportunities to raise awareness and empowe those most in need and deliver better services. Emphasis on preventative health was seen as central to achieving and then maintaining health and underlining this was seen to be good nutrition and a healthy diet, and the value of physical exercise. This needed to be embraced by the very social groups it was designed to impact upon. The emphasis therefore needed to be on addressing health through improvements to the social infrastructure and creating inter-professional working initiatives to tackle the problem – an entirely new concept for the NHS which, until then, had worked on its own. Early in the new millenium it was recognised that “people need to be supported more actively to make better decisions about their own health and welfare” (Wanless 2002, p2). Also, that this support needed to happen in a variety of social settings which individuals were most likely to access and that the emphasis needed to be on healthy living and making healthy choices, one being to increase their physical activity (DH 2004a). There needed, therefore, to be a cultural shift in order to see physical activity as a normal part of everyday life (DH 2005). We have thankfully moved away from the definition of health provided by the World Health Organisation (WHO) in 1946, which described health as “being a state of complete physical, mental and social well being and not merely the absence of disease or infirmity”. This static and therefore quiescent notion of health is nowadays replaced with an acknowledgement that health is a constantly changing state, very dependent upon both internal and external factors and one in which the individual has to recognise the need to change and be able to bring about that change. Therefore, as health professionals, we need to engage in strategies which increase awareness in others as to their health status, so as to enable healthy choices to be made, but also be realistic and acknowledge that some changes are beyond the individual’s control at that time.


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Physical activity as a public health strategy “A little bit of exercise goes a long way” Joseph Stengle (2007)

The benefits of physical activity are emphasised in a number of government service agreement targets (DH 2004b, DH 2005, NICE 2008) including reducing morbidity and mortality due to diabetes, coronary heart disease, lung disease, high blood pressure and strokes and some cancers. The government also wants to reduce the increasing number of children and young people becoming obese and the number of obese adults. Urinary stress incontinence is also a concern and especially in women. With a strong link to obesity, it currently accounts for a significant chunk of the total NHS financial budget. Indeed, Thaker and Stanton (2000) reported that the condition accounted for approximately £424 million in the financial NHS budget of that year, overtaking, for the first time, the whole budget for the treatment of diabetes mellitus. Realistically, one would expect this figure to have increased significantly since then. Another concern is the increasing numbers of adults developing mental illness and the number of elderly people suffering from pre-senile dementia, senility and Alzheimer’s disease, all of whom may be helped by engaging in some form of physical exercise, in order to improve systemic circulation and particularly to help brain perfusion. Physical exercise is therefore appropriate and beneficial to health (Primatesta 2004). Current evidence suggests that six out of every ten men and seven out of every ten women are not active enough to benefit their health (DH 2003). Of particular interest to midwives will be the two topics recently referred to the National Institute for Clinical Excellence (NICE) by the Department of Health (NICE/ DH 2008): prevention of excess weight gain in pregnancy and weight management following childbirth. Both are currently considered central to the avoidance of antenatal maternal and foetal morbidity and mortality, and to health and well being post-delivery. The bulk of academic studies regarding the benefits of physical activity have been conducted in the USA, mainly due to America having had an obesity problem across all sectors of its population for longer than reported in the UK. National surveys concluded that nearly twice as many American women were sedentary during their pregnancies compared to the national average of US adults (Zhang and Savitz 1996). A study undertaken by Peterson, Leet and Brownson (2005) among American mothers in the 18–44 age groups suggested that American women had less social opportunity to engage in moderate to vigorous intensity exercise, due to their lifestyles and instead engaged in low intensity activities such as walking. In pregnancy, mothers also shied away from moderate activity and this was more evident in the older age group interviewed. There might be seemingly obvious reasons for this, such as an individual’s fear of applying undue risk to their pregnancy, but there is also robust evidence which places the problem firmly within the public domain, citing general lifestyle trends such as the move to more sedentary occupations and leisure activities. The issue, however, seems far more complex and may include factors such as social groupings, ethnicity, the media, finances and food trends. American guidelines drive our UK ones and the American College of Sports Medicine (ACSM) currently recommends a minimum of 30 minutes of moderate physical activity daily to improve the health and well being of all individuals. The American Colleges of Obstetrics and Gynaecology (ACOG) also recommend that pregnant women should exercise to a similar moderate level daily (Treuth, Butte and Puyau 2005). This, however, depends upon there being no medical complications and the pregnancy being defined as normal or low risk.This position is endorsed by the Royal College of Obstetricians within the UK (RCOG 2006). The woman’s general fitness level needs to be considered before she embarks upon any new type of physical activity/exercise routine. Starting points are individual and should be assessed by a suitably trained exercise professional who is completely familiar with the physiological changes of pregnancy. Some types of activity are considered unsuitable due to those specific changes, and these include weight bearing exercise due to the added stresses placed upon the body by the growing foetus, contact sports due to the potential for injuring the unborn foetus and no scuba diving due to the extra demands within the foetal circulation for


Public health, physical activity and aquanatal exercise oxygen. Mothers new to physical exercise are also recommended to refrain from starting any new exercise routine prior to their completed twelfth week of pregnancy, in order to minimise the risk of an early miscarriage. Interestingly, this requirement is not scientifically supported by the evidence. There is no absolute clear indication to suggest that engaging in moderate physical activity before this time contributes to a miscarriage, except for some vague studies conducted on animals, which looked at thermoregulation. They suggested that “inappropriate” (too intense) exercise might result in hyperthermia in the mother and this might influence cell division in the developing embryo. As a consequence, foetal malformations might potentially cause a miscarriage (Riemann and Kanstrup Hansen 2000). It therefore appears that this specific gestational requirement has been recommended from a defensive position in order to minimise any possible litigation. However, mothers who are well used to moderate exercise can be advised to carry on with their daily routines right from pregnancy diagnosis, which more often than not is as early as the sixth week of pregnancy. This indicates that there is a contradictory message being given to women: that the physically active mother is OK, but that any new activity can be potentially dangerous to foetal health. It is not surprising that, once pregnant, mothers seem to adopt a “safety” position and choose not to begin low to moderate exercise at all. This highlights the importance of all women becoming used to engaging in moderate physical exercise long before they become pregnant, by being a part of a society which sees exercise as normal and therefore an expected activity. If we consider a salient aim of antenatal care is to improve the general health and well being of mothers, then we need to be endorsing programmes of physical activity more dynamically than we currently do, so that mothers can complete their pregnancy journey in better physical shape than when they started it. This, however, depends upon us and the value we place on exercise ourselves. An unpublished qualitative study by the authors in 2002, interviewing 50 midwives within several NHS trusts, highlighted that it was not generally considered to be one of their roles to advise mothers about exercise once pregnant. They commonly felt that they did not have enough information about the topic and felt uneasy when it was under discussion. However, and of particular interest, they did see it as their role to provide nutritional advice. Respondents also frequently included statements such as ”we can back up the nutritional advice with glossy leaflets” [which were also read sometimes by themselves] “but there do not seem to be as many leaflets about physical exercise”. [Highlighting they did not seek them out]. Many were unaware of what advice to give their clients, especially regarding the types of activities considered to be safe, or how the changing pregnancy physiology might affect their choices. Interestingly, however, when asked, all could recite the physiological effects of pregnancy on diabetes mellitus and similarly could say how diabetes mellitus impacted upon pregnancy. This suggests that midwives are very quickly professionally socialised into the abnormal at the very real expense of knowing about and therefore supporting normal daily behaviour during pregnancy. The benefits of physical activity during pregnancy are considered to be related to the avoidance and management of excessive weight gain. For example, Dempsey, Butler, Sorenson et al (2004) suggest that exercise might reduce the risk of the mother developing gestational diabetes mellitus by helping to regulate hormonal activity within the body. This is especially beneficial in those women considered to be morbidly obese (BMI > 33) (Dye, Knox, Artal et al 1997). It may also help in avoiding pre-eclampsia by helping to normalise blood pressure and therefore reduce the likelihood of Pregnancy Induced Hypertension (PIH), although the mechanism by which this might happen is so far not fully understood (Saftlas, Logsden-Sackett, Wang et al 2004). Other benefits of mothers engaging in physical exercise in pregnancy are related to the musculoskeletal system, especially in helping lower back pain, strengthening the abdomen, toning the pelvic floor and creating better psychological health. The ACOG support the practice of screening mothers before they embark upon a particular physical activity and recommend special consideration is applied to maternal thermoregulation during any form of structured exercise (ACOG 2003). Soultanakis (2003) describes how heat is produced by the muscles of the body, by the intake of food and in response to vital bodily functions. This energy is known as the basal metabolic rate. Thermoregulation is achieved by a balance between the

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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals heat being produced by the body and the heat lost (evaporation, conduction, convection, radiation). The body needs to maintain homeostasis and this is especially important but often more difficult during pregnancy, due to the extra amounts of energy required for the developing foetus. It is considered best practice within programmes of exercise to ensure that the activity does not raise the core temperature by more than 1.5°C above the resting temperature. Exceeding this, the energy and therefore oxygen requirements of the mother’s body are raised and can create stress to the mother but more importantly can contribute to foetal tachycardia. The exercise environment, ambient temperature and the duration and intensity of the exercise needs to be considered carefully as do the hydration levels of the mother. McArdle, Katch and Katch (1991) state that fluid loss of only 1% of the body’s total mass can raise the core temperature significantly. Recommendations to mothers for preventing hyperthermia include: ● Engage in appropriate and safe exercise. ● Work at your own pace – exercise should not be competitive ● Acclimatise gradually ● Ensure the exercise is taking place in a suitable environment – not too hot (or too cold) ● Exercise with others in order to ensure safety ● Wear appropriate clothing for the type of exercise ● Ensure adequate intake of fluids ● Be aware of your body and heed any warning signs.

Aquanatal exercise as a public health strategy. “If all the benefits of exercise could be packaged in a single pill, it would be the most widely prescribed pill in the world!” “Dr Nick”.com (Professionalization of Exercise Physiology online)

Aquanatal exercise is a valuable public health strategy as it can be seen as an appropriate and safe form of physical exercise for pregnancy (Katz 2003). It is the only form of physical exercise which provides the mother with a totally holistic workout which therefore reduces stress and strain on any one particular part of the body. It utilises the properties of warm water, which is an extremely dynamic and powerful medium within which to exercise and seems to afford the foetus protection which dry land exercise does not, by helping the mother to maintain her core body temperature when exercising in water with subsequently less risk of the foetus developing tachycardia (Katz, McMurray, Berry and Cefalo 1988). Further, Clapp (1991) has suggested that women generally struggle to exercise on dry land in hotter weather, but when exercising in warm water they can continue with no problems due to its unique benefits. The public health guidance launched by NICE and the Department of Health (NICE Guidance No 2, 2006) and entitled “Four commonly used methods to increase physical activity” explores practical opportunities for health professionals to highlight the benefits of physical exercise within the general population. It advocates the use of ad hoc opportunistic brief chats regarding exercise, issuing individuals with pedometers to increase awareness of how much exercise they are in fact getting, and also to increase their motivation and promoting more opportunities to walk and cycle and engaging in exercise referral schemes. It is the latter which appears the most interesting for pregnancy, as it conjures up a vision of a very practical and entirely appropriate way of ensuring all mothers can get access to aquanatal exercise if they so choose, by being referred to sessions by their General Practitioner (primary care physician). We would also suggest that a natural second step would be for the woman’s own midwife similarly to use the pregnancy exercise referral scheme. We would hope however, that protected and paid time off from paid employment would also be arranged should the


Public health, physical activity and aquanatal exercise mother require it. We suggest the following guidance for pregnancy based on all of the points raised so far within the public health agenda: ● Physical activity being seen by everyone in society as a normal and thus expected lifestyle choice ● Physical activity and nutrition being seen as the foundation stones to achieving and maintaining health ● Physical activity being seen as intrinsic to the normal physiological process that is childbirth ● Pregnancy and childbirth being seen as normal parts of a woman’s life cycle ● Physical activity being seen as a dynamic continuum – for all stages of a woman’s life. We have formulated our own specimen guidelines for the support and surveillance of mothers during pregnancy (see The Holistic Lifestyle Model of Care for Pregnancy, p 68). You will note that we have not separated antenatal care from postnatal care, as we see it as a continuum and therefore we refer to it as the Pregnancy to Parenting Journal. We selected the last word carefully as a journal is a dynamic log, completed during a journey. It places diet and physical activity firmly at the beginning of care and considers these two topics as intrinsic and fundamental to normal health and well being. Pregnancy surveillance and support are then added on. Later, following the birth, these components are replaced by ones concerning recovery, parenting and baby nurturing. Finally, all these extra components are removed from the journal at the end of the pregnancy episode and only the diet and exercise ones will remain as they were at the beginning, for the mother’s new life ahead. We feel passionately, that if childbirth was seen as an addition to normal physiology and health in this way, in direct contrast to it being the most central focus, mothers would also see it as a completely normal part of their lives, and the fear of childbirth might be alleviated to allow more mothers to gain birthing confidence. More normal, home and water births could, we feel, ensue. Many other problems arising in both the antenatal and postnatal periods could be avoided. Examples being excessive weight gain and its management, anaemia and other dietary issues, heartburn, morning sickness, constipation, postural problems, back ache, symphysis pubis dysfunction and low energy levels, to name but a few, and also the more severe and life threatening conditions such as hypertension and preeclampsia, which are currently linked to lifestyle factors and weight gain. We also feel that, as diet and exercise will be considered more thoroughly, there will be positive impact on maternal psychological health and as a direct consequence post natal depression rates will fall and general happiness scores will improve. We believe that there is a real need to try something new within maternity and midwifery care. Midwives would still be responsible for ensuring the safety of the mother during the pregnancy episode, but they would be part of a wider multi-professional team of exercise and fitness coaches, nutritionists and dieticians, with the woman’s primary care physician also having an input. We feel this model would allow midwives to actually do the job they are trained to do and actually be the expert for the pregnancy part, and relinquish the other parts to those professionalswho are better trained on those areas.

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The Holistic Lifestyle Model of Care for Pregnancy (or Pregnancy to Parenting Journal) My Nutritionist is _______________________________________________ My Exercise Referral Coach is _____________________________________ My Midwife is _________________________________________________ First visit (ideally under 12 weeks) At the GP’s surgery/health centre – to meet nutritionist and exercise referral coach. Aim to take a detailed lifestyle history. Review diet and nutritional requirements for pregnancy, advice regarding any dietary supplementation and eating disorders, nausea/vomiting dietary advice and calorific energy requirements for the developing baby. Check BMI and devise a moderate physical activity exercise plan for this first trimester following assessment of blood pressure. Possible exercise could include aquanatal, details of local “walking clubs”, Pilates, yoga, swimming. Tips on how to increase activity in the home. Postural advice and moving and lifting information. First contact with midwife Aim to take a detailed medical, obstetric and social history. Highlight any risk factors – offer prompt referral to medical practitioner. Discuss pregnancy choices, including place and type of birth. Provide initial and basic information on breast feeding and parent education classes, discuss employment rights etc. Offer blood profile testing and urinalysis. Offer ultrasound scan and arrange same if desired. Subsequent community appointments (in line with NICE guidance) See nutritionist and exercise referral coach – assess weight and daily diet, suggest healthy meals for the mother and her partner. Assess general fitness level including blood pressure. Review/amend exercise referral prescription. See midwife – check urinalysis. Physical midwifery check up and abdominal examination. Discuss topics suitable for this stage of pregnancy, including more information on breastfeeding, keeping healthy and preparing for birth and parenting. We feel that by seeing a nutritionist and exercise referral coach at every visit, the mother will receive better quality advice on these two topics. It will also allow the mother to receive better quality midwifery care, as her midwife will have more time to discuss and advise on pregnancy related issues. The midwife will be freed up to practise her art, which is pure midwifery. All communications will be contemporaneously recorded within the mother’s back up notes and in her hand held journal.

“We must become the change agent we want to see” (Mahatma Ghandi) (www.wikiquote.org)


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Public health, physical activity and aquanatal exercise

To summarise ● Exercise and nutrition are seen as the foundation stones to achieving and maintaining health and well being. ● The majority of evidence relating to the benefits of physical activity originates from the USA. ● Illnesses linked to obesity account for a large slice of the total NHS budget. ● Water based exercise is beneficial in pregnancy due to it being appropriate and safe.

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References Acheson, D. (1988) Public Health in England: The Report of the Committee of Inquiry into the Future Development of the Public Health Function. London: The Stationery Office. American College of Sports Medicine www.acsm.org (last accessed 17.12.09). American Congress of Obstetricians and Gynecologists (2003) Exercise During Pregnancy and the Postpartum Period. Clinical Obstetrics & Gynaecology 46 (2): 496–499. Clapp, J.F. (1991) The changing thermal response to endurance exercise during pregnancy. American Journal of Obstetrics and Gynaecology 165: 1684–1689. Dempsey, J.C. , Butler, C.L., Sorenson, T.K., Lee, I-M., Thompson, M.L., Miller, R.S., Frederick, I.O. and Williams, M.A. (2004) A case control study of maternal recreational physical activity and risk of gestational diabetes mellitus. Diabetes Research Clinical Practice 66: 203–215. Department of Health (1999) Saving Lives: Our Healthier Nation. London: DH. Department of Health (2003) Joint Health Surveys Unit (2003), Health Survey for England. London: DH. Department of Health (2004a) The Public Health White Paper, Choosing Health: Making Healthy Choices Easier. Executive summary. Nov 2004. London: DH. Department of Health (2004b) At Least 5 A Week: Evidence on the Impact of Physical Activity and Its Relationship to Health. The Chief Medical Officer’s Report. London: DH. Department of Health (2005) Choosing Activity: A Physical Activity Action Plan. London: DH. Dye, T.D., Knox, K.L., Artal, R, Aubrey, R.H. and Wojtowycz, M.A. (1997) Physical Activity, Obesity and Diabetes in Pregnancy. American Journal of Epidemiology 146 (11): 961–965. Katz, V.L., McMurray, R., Berry, M. J., Cefalo, R.C. (1988) Fetal and Uterine Responses to Immersion and Exercise. American Journal of Obstetrics & Gynaecology 72: 225–230. Katz V.L. (2003) Exercise in Water During Pregnancy. Clinical Obstetrics and Gynecology June, 46(2): 432–441. New York: Lippincott Williams and Wilkins Inc. McArdle, W.D., Katch, F.L. and Katch, V. (1991) Exercise Physiology: Energy, Nutrition and Human Performance Philadelphia/London: LEA & Febger. National Institute for Health and Clinical Excellence (2006) Four commonly used methods to increase physical activity. March 2006. www.nice.org.uk/PH1002 (last accessed 25.11.09). National Institute for Health and Clinical Excellence (2008) 18th Work Programme: Clinical Guidelines and Public Health guidance, commissioned March 2008. London:DH. (www.dh.gov.uk accessed 17.11.09). PEP online. Professionalization of Exercise Physiology online. An international electronic journal for exercise physiologists. Vol 9, No 12. December 2006. Peterson, M., Leet, T.L. and Brownson, R.C. (2005) Correlates of Physical Activity among Pregnant Women in the United States. Medicine and Science in Sports and Exercise 37(10): 1748–1755. Primatesta, P. (2004) Health Survey for England 2004 – Updating of Trend Tables to Include 2004 data. London: DH. Riemann, M.K. and Kanstrup Hansen, I.L.(2000) Effects on the fetus of exercise in pregnancy. Scandinavian Journal of Medicine and Science in Sports 10 (1): 12–19. Royal College of Obstetricians and Gynaecologists. Exercise in Pregnancy. January 2006. Saftlas, A.P., Logsden-Sackett, N., Wang, W ., Woolson, R. and Bracken, M.B. (2004) Work, Leisure-time Physical Activity and Risk of Pre-Eclampsia and Gestational Hypertension. American Journal Of Epidemiology 160: 758–765. Soultanakis, H. (2003) Thermoregulation During Exercise in Pregnancy. Clinical Obstetrics and Gynaecology 46 (2): 442–455. Stengle, J. (2007) Getting in Shape Reduces Death Risk. New York: A & P Associated Press. Thaker, R. and Stanton, S. (2000) Management of Urinary Incontinence in women. British Medical Journal 25th Nov 321: 1326–1331. Treuth, M.S., Butte, N.F. and Puyau, M. (2005) Pregnancy-related Changes in Physical Activity, Fitness and Strength. Medicine and Science in Sports and Exercise 37 (5): 832–837. Wanless, D. (2002) Securing our Future Health: Taking a Long-term View. London: HM Treasury. Wood, W. (1867) Manual of Physical Exercises: Rules for Training and Sanitary Suggestions. New York: Harper & Brothers Publishers. World Health Organisation (1946) Constitution. New York: World Health Organisation. Zhang, J. and Savitz, D. (1996) Exercise During Pregnancy Among US Women. Annals of of Epidemiology 6: 53–59.


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Chapter 11 Aquanatal exercise and parent education Pregnancy is a major life changing event and at some point all parents will begin to consider how the birth of their child (or children) will eventually impact upon their lives in both positive and negative terms. The realities associated with practical parenting were once socially lived experiences, passed on from generation to generation within close community groups. With many mothers now living very different lives and very often isolated from their biological families, programmes of formal antenatal and parent education have become a surrogate support. Indeed many Doula agencies have sprung up across the UK to offer the birthing support and help a mother would have provided for her daughter years ago. The middle classes may be seen as absolutely the wrong people to attend NHS programmes of parent education as they are in social positions which enable self directed access to information. Affluence and social position, as defined by either employment or traditional family ancestry can be perceived as a means of naturally overcoming the anxieties of the birthing process itself and of becoming effective parents. Thankfully there is currently an increased general awareness of the needs of this vulnerable group, but even so, it often falls on the private and independent sector to provide classes as the NHS struggles to direct its finite resources for the benefit of the more socially compromised mother. Whilst there is plenty of information out there, it also needs to be understood. It is often too easy for us to equate availability of information with the process of learning itself. Midwives need to facilitate the learning process in parents by gently supporting, directing and generating appropriate opportunities for enquiry and discussion and engaging with the art of professional “story telling”, thereby creating empathy and treating birth individually and sensitively. This helps to build self confidence for their future role as effective parents. That said, there is a need to avoid traditional ways of teaching, which are generally didactic in approach and which utilise the lecture, placing the midwife in a position of power, as the controlling factor within the group. Wiener and Rogers (2008) explore the issues relating to the traditional method of teaching parenthood, and refer to what they term as the issue of the “brick wall of labour”. They discuss this as a barrier created by a formal systems approach of providing parent education classes, where the emphasis is always on the actual labour episode. They refer to how the midwife and the parents perceive it as an invisible barrier with all routes leading to it and an inability to get either over or around it. Due to time constraints, the “wall” blocks the exploration of other qualitative dialogue such as the psychological adaptations to becoming actual parents and therefore renders the sessions of little practical use. Daniel (2008) emphasises that the first six weeks of a newborn’s life are now recognised as being the most stressful for new parents. Skills and coping strategies are therefore needed to smooth the way for an effective post birth transition and for effective long term parenting. It is now accepted in the world of psychotherapy that the quality of the parent–child relationship has an enormous impact on the future of the child’s emotional well being, self esteem, mental health and resilience in life (DH 2004). Therefore it needs to be recognised that by selecting the right learning environment, adopting the right style and having the right facilitator who is motivated to teach, a good quality experience for all can be achieved which can also impact positively on society (Balbernie 2004). Current tendering for


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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals contracts across the NHS in the UK as a result of re-configuration exercises has led to many independent and private agencies tendering and successfully gaining control of parent education programmes. Only time will tell if this will be evaluated as positive, as, to date, evaluation of parent education is somewhat difficult due to the process not always supporting the most positive outcome. Some mothers can attend every class imaginable and still have a poor outcome, but it must be recognised that the classes might have made some subtle difference to their lives albeit if only in terms of their ability to cope. Much financial energy has been directed to those seen as socially disadvantaged, and rightly so, but it needs to be recognised that all mothers and families have their own individual needs, regardless of their positions within our society and there is a need to balance care and educational support with fairness. Sure Start, a product of the nineties, aimed to reduce social inequality within childbearing and parenting by offering extra social and fiscal support to those families categorised as being most in need. The focus was, and still is today, on reducing the determinants of social deprivation generally by introducing social contracts and cash payments instead of valuing education as a means to develop. Parent education is very often added as an extra to the menu of services on offer to mothers and their families, as opposed to being a core element. Finances, or the lack of them, now seem to be the fundamental issue. There is a historical perception that social deprivation equates to ineffective parenting, and sadly this attitude is perpetuated in the practice of some healthcare professionals today. Whilst it is evident that birthing poverty and social compromise might impact significantly on birth outcome in the mainly physical sense, it needs to be appreciated that very often excellent naturally constructed social frameworks already exist for these groups to benefit from. Their needs realistically might be concerned with other lifestyle issues such as practically coping with a lack of private transport, poor housing and unemployment, as opposed to the issues facing the middle and more affluent classes in society such as not having the benefit of close family support. Other social groups, such as immigrants and asylum seekers, may also experience great social isolation. According to Pearson and Thurston (2006), government initiatives such as Sure Start support only a small proportion of the childbearing population and thus can compartmentalise individuals and reduce the likelihood of social inclusion. Currently, social integration whilst respecting individual diversity is high on government agendas. Consideration needs to be given to establishing strategies which bring people together and establish supportive frameworks for their long term benefit. As health professionals, there is a need to ask: Are separate community services for different ethnic groups, younger, and older mothers the ideal? Do mothers and their families really benefit from continuing social separation? What effects can this have on the future of our society as a whole? Surely there needs to be a new vision for providing programmes of parent education, within which all social groupings can benefit and which can offer parent education and health promotion seamlessly within a context of healthy living and social support. Such programmes would focus on individual achievement whilst also harnessing the diversity of the group to aid understanding and social insight and offer peer support into the realities and practicalities of childbirth and beyond. “Women should have easy access to supportive, high quality maternity services designed around their needs” (DH 2004). Aquanatal exercise has the potential to offer a new and dynamic form of parent education by creating the right environment, utilising the right strategies and having the benefit of a highly motivated facilitator. Daniel (2008) describes the importance of tapping into the wealth of knowledge and experience of a learning group. He describes it as the “power” of the group. Interestingly, each aquanatal group is diverse in terms of the ages, social and ethnic backgrounds and affluence contained within it. This is very powerful indeed. The aquanatal coach can harness this power throughout the session by appropriately engaging practical, cognitive and affective learning strategies (Petty 1998). Walsh (2006) describes this as a “refreshing change” as the approach to learning centres around the pool environment. There are no formal barriers to self expression and there is an equal distribution of power from both the professional and the group perspective. The benefits are immense; the group forges a holistic sense of belonging and peer support, together with sensitivity to


Aquanatal exercise and parent education each other’s individuality. Long term relationships are created and a feeling of mutual trust in a sort of “all girls together” environment (Baines 2006, unpublished study). The warm water environment is relaxing and entirely conducive to enjoyment, which needs to precede effective learning. The benefits are holistic; whilst the body is being exercised the mind is also. Walsh (2006) refers to the “Baines method” as a way of reinventing antenatal education, and its transformative educational power needs to be researched further, to allow the issues of talking openly about birth and the transition to parenthood to be evaluated within this new environment. One thing is clear, however: more attention needs to be directed to normative forms of parenting in the community so that the focus is on how to get birth right instead of what can go wrong.

Practical implications of facilitating parent education at the pool Physical factors As learning sessions will involve the class being in the water it is paramount that the group does not become chilled, so physical innovation is the key here – learning whilst moving! You will very soon become creative in your thinking, generating lots of ideas for maximising learning in your classes. Examples could include, briefing mothers on posture and lifting and bending, by using yourself as a visible resource when on the pool side. Topics such as caring for the pelvic floor can be revisited time after time with a ‘drip feed’ of information. An innovative way is to take the anatomical pelvis/laminated pictures into the water to give visual aid to the exerciser, who may not know where their pelvic floor is, let alone how to exercise it. Group discussion and funny anecdotes during the exercises can also be used to generate health awareness. This way of learning could prove to be a life changing experience for some women. The knowledge and information gained could impact positively on pelvic floor and general health in later years. (The pelvic floor is examined in more detail in Chapter 8.) The normal process of birth could also be explored in this dynamic way, using the anatomical pelvis to explain how gravity can assist the passage of the foetus and aid birth outcome. By providing each mother with their own plastic pelvis during the class, the visualisation process is further enhanced. Practical demonstration and discussion of effective positions for labour and birth can also be demonstrated, as can different presentations of the foetus. By supporting mothers to play in the water, they can practise positions and concepts without fear of embarrassment, later to be used during the birth. Mothers can hopefully begin to see their own bodies more clearly and also develop their confidence in birth as a normal physiological event. This confidence is powerful indeed and can lead to a higher incidence of normal and particularly home births (Baines 2006).

Social factors The relaxation component of an aquanatal session is often used as a time out for some women and an opportunity to bond with their unborn babies and there can be a distinct pull for some women to float towards others in order to engage them in conversation and thus interact. Interestingly, from observing many mothers over the last decade, we frequently see a young teenage mother actively engaged in a conversation with an older mother, for example, and this continues later in the changing room! These social interactions are wonderful and so positive for all concerned, as our research has informed us. We have had many aquanatal friendships blossom in this way and frequently hear from mothers who attended our classes years ago, telling us their friendships are still as strong. The aquanatal coach can join in with the more vocal groups and use their time constructively to offer more advice or information as required. Looking back to the medieval period in history, upright birthing positions were normal and births were a ritual where women would gather to support the labouring woman and have a good gossip whilst the normal process of birth took place. In this case women are gossiping before the event! Generations ago, candles would be lit, curtains drawn and keyholes blocked out for privacy, creating a warm safe environment for the labouring woman, who would be supported on a birthing stool in front of the hearth. Interestingly, this compares to

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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals the aquatic environment antenatally today, and to the home when a birthing pool is used. The water environment is private, the water is warm and relaxing, a medium for comfort and thus perceived safety. When in the water, mothers begin to behave in a sort of primitive tribal fashion, gathering in small groups and demonstrating primitive body language, such as using their hands to communicate and bending their torsos down in the water to achieve maximum benefit. We learn in so many different ways about life and the world around us, but “story telling” is currently deemed to be a very effective teaching strategy. Story telling allows the imagination of both the narrator and the listener to flourish and simultaneously to develop ideas and explore feelings. In this way, the power of the mind can be harnessed to influence outcome. The aquanatal coach can select a small narrative to share with her group each week and then ask the group to consider it whilst they are then exercising. Not only Fig. 11.1 Upright birthing position does this enable the coach to assess exertion level it also adds interest. What does it mean to them? What would they do for example? Shannon and Weaver were scientists who, in the 1940s, devised a famous model of communication that can be applied to any situation where a message (in this case an educational one) needs to get from one person to another. It is frequently used in the study of complex human communication. In this model noise is perceived as a barrier to effective communication being sent or received, so small intimate teaching groups are key. When in the water, the coach can invite the mothers to share stories about themselves, perhaps about their relationships or their families, their hopes and their fears for the future. These small informal stories can be very powerful to the group but the coach needs to ensure confidentiality will be maintained and that the stories are completely optional. The coach can also bring props to the pool to enhance the visual and psychomotor aspect of learning. New skills can be learned as well. Recently a group of aquanatal mothers learned to knit, as one of the group each week demonstrated the skill, after the class, over a warm drink in the lounge area. All the mothers had created a small item of baby clothing by the time they had completed the classes.

Facilitating learning By fostering and building a caring relationship with your class you will naturally achieve the status of mentor (Covey 1999) and when this is established, the group will feel that the information that you are giving them is in their very best interests (Huczynski 2007). The previously referred to “wall of labour” that seems to dominate any topic in pregnancy can be gently scaled to include a more normal focus on actually becoming a parent. Currently, problem based or enquiry based learning is in vogue, and whether you are a midwife, medical student or school child, there is a recognition that effective learning can take place when individuals work as part of an evidence gathering group (Boud and Feletti 1997). The use of this type of teaching in parenting classes is relatively uncommon and not documented in any contemporary literature. However, in a small qualitative pilot study, Murphy (2002) documented the use of enquiry based learning within parent education and reported that it benefited group dynamics, group and individual behaviour and group cohesiveness.There was a marked difference to the standard group approach. However the most noticeable difference recorded was the hunger for information and the freedom to ask questions, by everyone in the group. By engaging


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Aquanatal exercise and parent education individuals in this way, education can be seen as enjoyable whilst still respecting the individual’s personal autonomy. As a practising midwife offering parent education in the aquatic environment you will be fulfilling the NICE Guidelines (2008) which support entrepreneurial practice within the community setting. In addition to the benefits of providing parent education in this way, you will be facilitating a truly holistic workout for a woman’s body, including her brain, and thus you will be helping her to develop her parenting skills.

To summarise ● An aquanatal exercise class provides an excellent environment for facilitating holistic and meaningful parent education. ● The opportunities for creative learning are immense and support the midwife’s role as a childbirth educator and health promoter. ● The strategy should be for all to enjoy and benefit from. ● NHS funding would ideally support all mothers who choose to attend

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References Baines, S.M. (2006) Women’s perceptions regarding the benefits of attending aquanatal exercise – A qualitative two-year longitudinal study, University of Salford, UK. (unpublished). Balbernie, R. (2004) A Short Start in Sure Start, cited in Midirs Midwifery digest 14(3) 2004: 408 –411. Boud, D. and Feletti, G. (1997) (editors) The Challenges of Problem Based Learning 2nd edition. London: Kogan Page. Covey, S.R. (1999) Principle centred leadership. London: Simon & Schuster: 119 –129. Daniel, L. (2008) Information for new parents. British Journal of Midwifery February 16 (2): 115. Department of Health (1993 ) Changing Childbirth. Report of the expert Maternity Group: HMSO. London. Department of Health (2004) The National Service Framework for Children, Young People and Maternity Services. www.dh.gov.uk (accessed on 20.04.09). Greene E (2008) Pregnancy and childbirth for the Historical Author. Elena Greene’s notes on history of pregnancy and childbirth. www.elenagreene.com (last accessed 12.01.10). Henty, D. (1998) Brought to bed: a critical look at birthing positions. Royal College of Midwives Journal 1998 1 (10): 310 – 313. Huczynski, A. (2007) Workshop on influencing skills. Ronald Millar Suite, Wishaw General Hospital, Lanarkshire. Murphy, S. (2002) Empowering parents to make decisions in childbirth by enquiry based learning. Unpublished qualitative study on traditional versus enquiry methods of teaching parent education. East Kilbride, Lanarkshire. National Institute for Health and Clinical Excellence (2008) Antenatal care: Routine care for the healthy pregnant woman. www.nice.org.uk.html pp.12, 17 and 54 (accessed 12.04.09). Pearson, C. and Thurston, M. (2006) Understanding mothers’ engagement with antenatal parent education services. Children and Society 20 (5): 348–359 (12) London: Blackwell. Petty, G. (1998) Teaching Today: a practical guide. Cheltenham: Stanley Thornes (Publishers) Ltd. Shannon, C.E. and Weaver, W. (1947) The Mathematical Theory of Communication. USA: Illinois Press. Walsh, D. (2006) A new dawn for antenatal education: taking a fresh approach. British Journal of Midwifery 2nd Feb 14 (2): 82. Wiener, A. and Rogers, C. (2008) Antenatal classes: women can’t think beyond labour. British Journal of Midwifery February 16 (2): 121.

Useful sources of Information www.parentlineplus.org.uk – good source of parent education information (last accessed 19.10.09). www.parentinguk.org – a national organisation for those working with parents – provides useful information, news and links (last accessed 19.10.09). www.direct.gov.uk – the government website for parent advice (last accessed 19.10.09). www.QIA.org.uk – free articles and papers and guides (last accessed 19.10.09). www.literacytrust.org.uk – produces lots of leaflets on a wide variety of topics for parents and a site to read the views of parents themselves (last accessed 19.10.09).


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Chapter 12 Nutrition during pregnancy and for physical exercise “Food is our common ground, a universal experience” (James Beard 1903–1985) (www.foodreference.com)

This chapter aims to provide a general overview of nutrition during pregnancy and the dietary requirements for mothers who engage in physical exercise. Nutrition and physical exercise share a common link and are accepted as the foundation stones to achieving and maintaining good health. A nutritionally balanced diet is seen as the key to healthy living and to maintaining a sensibly healthy weight. Some would argue that there are no such things as unhealthy foods, but that our diets can become unhealthy due to an imbalance in the types and quantities of foods we ingest. There is plenty of advice out there for pregnant women regarding diet. Additionally there is conflicting advice based on the continually changing list of foods described as “bad” and to be avoided whilst pregnant. Midwives and other health and fitness professionals base their practice on applying the scientific evidence in an attempt to keep mums and their unborn babies healthy and therefore as safe as possible. There is a generally accepted consensus that certain foods should not be consumed during pregnancy: raw fish and egg yolks, undercooked meat, unwashed salads and vegetables and unprocessed cheese (DH 2009). We tend to offer a brief chat about nutrition in early pregnancy, back this up with a variety of leaflets and then instruct mothers not to embark upon any form of slimming diet during this time. As health professionals, we have a responsibility to ensure that we explain the benefits of needing to adjust the diet when pregnant whilst also ensuring that a dietary imbalance is not created due to the avoidance of certain foodstuffs. We feel that a super opportunity for exploring nutrition and healthy eating for pregnancy is when mothers attend aquanatal exercise as we can discuss issues in a naturally relaxed environment. Evidence suggests that birth weights count (Macfarlane and Mugford 1984, Relton 2005). In a significant British study, Relton (2005) suggested that low levels of dietary folate significantly affect the final weight of the baby. She suggests that folic acid and vitamin B12 are still considered to be vital nutritional supplements for foetal health. A report commissioned by the UK Fabian Society in 2007, identified that social deprivation, which includes poor access to a nutritionally balanced diet, is still a key factor in the “alarming” birth weight statistics reported across Britain. Their report highlights that birth weights on the whole have not increased in line with advances in technology and maternal surveillance, as would be expected. In 1989, they reported that 67 out of every 1,000 live births were classed as low birth weight, using the generally agreed definition of below 2.5kg (WHO 2004) but that in 2006 this figure had risen to 78. Currently there is concern regarding the soaring levels of obesity within the western world. The British government has responded by setting up national and regional task forces to look at the issues and consider the way forward (DH 2006). Nutritional awareness and more emphasis on physical activity are seen as


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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals important to making any sort of impact; and further, that pregnancy is a time to promote the benefits of good nutrition, healthy eating and physical activity (DH 2004). We need to ensure that mothers do not attend our aquanatal classes in an attempt to lose weight. Rather that they see our classes as a way of moderating their previous physical activity levels, or an opportunity to begin to exercise safely. Aquanatal coaches need to be confident with the nutritional advice we offer. This means having a current knowledge of healthy eating for pregnancy. In order to do this we also need to be completely familiar with the changes taking place within the woman’s body as a result of pregnancy and how these physiological changes impact on dietary and energy needs for physical exercise. Body mass and weight is determined by many factors, maternal age being one. The teenage mother for example, will have different dietary needs during her pregnancy to those of the older mother. Individual body size and mass need to be considered when planning aquanatal exercise, as within a mixed pregnant group, all the women’s energy and physical ability levels will differ. Similarly, weight gain during pregnancy will differ: Maternal BMI (at the start of pregnancy)

Recommended weight gain in kg (metric)

Recommended weight gain in lbs (imperial)

Low = BMI 19.8 or below

12–18 kgs

28–40 lbs

Normal = BMI 19.8–26

11.5–16 kgs

25–35 lbs

High = BMI 26–29

7–11.5 kgs

15–25 lbs

(American College of Obstetricians and Gynaecologists 2006)

When a woman asks, “How much weight should I expect to gain in pregnancy?” how do you answer her? Do you refer back to her initial booking body mass index (BMI) and calculate the weight accordingly, or do you offer a generic amount, for example, “about 10 kg”? Do you further explore her current level of fitness and her individual daily energy requirements in arriving at your answer? Whilst we are not dieticians, if women are not able to access the appropriate professional advice, for reasons of cost or simply a lack of information, then we have to do the best we can and that is where a good aquanatal exercise coach can be of benefit. We need to be realistic and take account of the woman’s skeletal frame (general build) as well, as this will influence her BMI and therefore the weight she is expected to gain during pregnancy. Very often an individual can be flagged up as having a high BMI but they are merely more muscular and therefore fitter individuals. In order to calculate a BMI we need to: Work out height in metres, multiply by itself (A) Measure weight in kilograms (B) Divide weight by height squared (B ÷ A) The amount of food we need varies between individuals, according to; gender, body size, energy requirements and whether we need to grow or lose weight. Women are generally considered to be a high risk population due to their childbearing capabilities. Women’s reproductive cycles lead to a demand for more iron in the diet, but as only about 10–15% of total iron intake is absorbed by the small intestine, there needs to be enough stored at all times for the body’s needs. During pregnancy, the overuse of certain antacids can reduce stomach acidity and therefore inhibit iron absorption in the gut. Do we always check if the mother is taking non-prescribed antacids when iron deficiency anaemia is diagnosed? Similarly, do we always check that when such medication is prescribed it does not interact with iron absorption?


Nutrition during pregnancy and for physical exercise The correct SI unit for measuring energy is the “joule” 1 kilojoule (kJ) = 1000 joules (J) 1 megajoule (MJ) = 1000 kj = 239 kcal 1 kcal = 4.184 joules This equates to: 1 gram of carbohydrate = 4 kcal (approx) 1 gram of fat = 9 kcal 1 gram of protein = 4 kcal 1 gram of alcohol = 7 kcals Therefore 100 g of meat, for example, would equate to 400 kcal of usable energy. Recommended Daily Allowances (RDAs) of food are calculated over a one-week period and represent the levels of a nutrient considered sufficient to meet the nutritional needs of nearly all (97–98%) healthy individuals (American Food and Nutritional Board 2004). Food servings refer to all the population and pregnancy is no exception. However, one’s age, gender and activity levels need to be taken into account when calculating the most appropriate food servings. “My Pyramid” is a useful and well recognised tool for making these calculations and can be accessed at www.mypyramid.gov/ Fats/oils and sweets – (use sparingly) Meat/poultry/fish/eggs/pulses and beans (2–3 servings) Dairy/milk/yoghurt and cheese (2–3 servings) Fruit and vegetables (5 servings) Bread/rice/cereals and pasta (6–11 servings) There are six recognised food groups: 1. Proteins – if converted to amino acids can be used for energy, but mainly for building new proteins 2. Carbohydrates – the main energy source and used for cell and tissue synthesis 3. Fats – different types of good fats and essentially bad fats (e.g. trans fats) needed for energy, cell protection and metabolism, insulation, nerve and muscular response 4. Vitamins – micronutrients are needed for growth and general cellular health. Can be water soluble (B and C) fat soluble (A, D, E or K) 5. Minerals – for example, iron, copper, iodine, fluoride are needed for various functions throughout the body, e.g. copper is needed for enzyme synthesis and iodine for thyroid function 6. Water – makes up over half the weight of the body and is needed for cell replenishment and temperature regulation. Optimum nutrition: ● Less than 30% fat in our diet daily ● More than 55% carbohydrate in our diet daily ● Less than 15% protein in our diet daily (American Food and Nutritional Board 2004).

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Aquatic Exercise for Pregnancy: a resource book for midwives and health and fitness professionals During pregnancy, women need to increase their intake of protein, vitamins and water to meet the extra demands placed upon the body and also the needs of the growing foetus. Pregnancy increases energy requirements in terms of supporting a higher metabolic rate (between 200 and 500 extra kilocalories required). There is more strain on the cardiovascular and respiratory systems, an increase in maternal tissue needs and extra fat is being laid down in readiness for future energy requirements and for breastfeeding. Pregnant women need to ensure that they increase their fluid intake and drink 3 litres of fluid (this includes 10 cups of beverages) daily. It needs to be acknowledged, however, that very often these nutritional ideals can be influenced by the woman’s changing physiology and her individual susceptibility to the adjustments of pregnancy (commonly referred to as minor disorders e.g. nausea, vomiting, pica, loss of appetite, etc). If a woman increases her physical activity during pregnancy, she will need to consider meeting her additional energy requirements, as whilst physical exercise can be extremely beneficial it can also be physically exhausting if the mother is nutritionally depleted. We need therefore to advise mothers attending aquanatal exercise to eat a carbohydrate based meal four hours before exercising to restore liver glycogen levels. Blood glucose levels decrease more quickly in pregnant women when exercising and remain lower post exercise. Hypoglycaemia is more likely to occur as a result, so in readiness for the extra energy required, we need to advise women to eat a small carbohydrate snack one hour prior to exercising – a banana, a couple of biscuits, a small bowl of pasta, a slice of buttered toast, for example. We need to ensure that our sessions do not last for longer than 45 minutes; otherwise the extra energy requirements required will start to be diverted from her stores to meet need. We must also advise mothers to hydrate themselves as soon as possible after an exercise session and to have a carbohydrate meal as soon as they are able. High glycaemic ones are considered the best, which include foods such as white bread, new potatoes and rice. Adequate water intake is essential before, during and following physical exercise. Oxygen and nutrients need to be transported to the working muscles, and carbon dioxide and other metabolic waste products have to be transported away from the muscles. Heat needs to be dissipated and blood plasma volume needs to be maintained in order to regulate blood pressure and normal cardiovascular function. This, however relates more to dry land exercise as, when in water, the hydrostatic effects serve to increase intravascular volume (Baum 1998). This also has the added bonus of allowing renal function to continue and not temporarily stop as it does when exercising in air. It does this by the hormones, renin, angiotensin and vasopressin being reduced and anti-diuretic hormone being inhibited. Both the kidneys and the muscles continue to work effectively. This is a major reason why mothers regularly want to pass urine after only a short time of being in the pool and also why they pass copious amounts of urine following a session. One way of checking that mothers are not overdoing it in the water is to ask them to tell you the colour of their urine after a session and also if it feels hot. Pale straw coloured urine will have an osmolality (Osm/kg) of

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