Practices That a Pregnant Woman Should Avoid to Prevent Injury to Her Baby

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Number 804 (Replaces Committee Opinion Number 650, December 2015)

Committee on Obstetric Practice

This Commission Opinion was developed by the Committee on Obstetric Practice with the assistance of committee members Meredith L. Birsner, Md; and Cynthia Gyamfi-Bannerman, Medico, MSc.

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Abstruse: Exercise, defined as physical activeness consisting of planned, structured, and repetitive bodily movements done to improve one or more components of physical fettle, is an essential element of a healthy lifestyle, and obstetrician–gynecologists and other obstetric care providers should encourage their patients to go on or to embark practise every bit an important component of optimal health. Women who habitually engaged in vigorous-intensity aerobic activity or who were physically agile earlier pregnancy can continue these activities during pregnancy and the postpartum period. Observational studies of women who exercise during pregnancy have shown benefits such equally decreased gestational diabetes mellitus, cesarean nativity and operative vaginal delivery, and postpartum recovery time. Physical activity also can be an essential factor in the prevention of depressive disorders of women in the postpartum period. Physical action and exercise in pregnancy are associated with minimal risks and accept been shown to benefit most women, although some modification to exercise routines may be necessary considering of normal anatomic and physiologic changes and fetal requirements. In the absence of obstetric or medical complications or contraindications, physical activity in pregnancy is safe and desirable, and pregnant women should be encouraged to continue or to initiate safe physical activities. This document has been revised to incorporate recent evidence regarding the benefits and risks of physical activity and exercise during pregnancy and the postpartum menstruum.

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Recommendations

Regular physical activity in all phases of life, including pregnancy, promotes wellness benefits. Pregnancy is an platonic time for maintaining or adopting a healthy lifestyle and the American College of Obstetricians and Gynecologists makes the following recommendations:

• Physical activity and practice in pregnancy are associated with minimal risks and have been shown to do good about women, although some modification to do routines may be necessary because of normal anatomic and physiologic changes and fetal requirements.

• A thorough clinical evaluation should be conducted before recommending an practise program to ensure that a patient does not take a medical reason to avoid do.

• Women with uncomplicated pregnancies should be encouraged to engage in aerobic and strength-conditioning exercises before, during, and after pregnancy.

• Obstetrician–gynecologists and other obstetric care providers should evaluate women with medical or obstetric complications advisedly earlier making recommendations on physical action participation during pregnancy. Action restriction should not exist prescribed routinely as a treatment to reduce preterm birth.

• Additional research is needed to study the furnishings of practice on pregnancy-specific conditions and outcomes and to clarify farther effective behavioral counseling methods and the optimal type, frequency, and intensity of practice. Similar research is needed to create an improved evidence base of operations concerning the effects of occupational physical activity on maternal–fetal health.

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Introduction

This document has been revised to incorporate contempo evidence regarding the benefits and risks of physical activity and exercise during pregnancy and the postpartum menstruum. Physical activity , defined every bit any bodily move produced past the contraction of skeletal muscles 1 in all stages of life, maintains and improves cardiorespiratory fitness, reduces the risk of obesity and associated comorbidities, and results in greater longevity. Women who begin their pregnancy with a good for you lifestyle (eg, practice, good nutrition, nonsmoking) should be encouraged to maintain those healthy habits. Women who do non accept healthy lifestyles should be encouraged to view the prepregnancy flow and pregnancy as opportunities to embrace healthier routines. Do , defined every bit concrete activity consisting of planned, structured, and repetitive actual movements done to ameliorate one or more components of concrete fettle i, is an essential element of a healthy lifestyle, and obstetrician–gynecologists and other obstetric care providers should encourage their patients to continue or to embark exercise as an important component of optimal health.

The Earth Health Organization and the American Higher of Sports Medicine have issued bear witness-based recommendations indicating that the beneficial effects of exercise in most adults are indisputable and that the benefits far outweigh the risks 2 three.

The 2018 update to the U.South. Department of Health and Human Services Physical Activity Guidelines for Americans reinforces prior recommendations of at least 150 minutes of moderate intensity aerobic activity per week during pregnancy and the postpartum menstruation 4. This activity should be spread throughout the week. The guidelines advise that women who habitually engaged in vigorous-intensity aerobic activeness or who were physically active earlier pregnancy tin continue these activities during pregnancy and the postpartum period. Additionally, women who are pregnant should be under the care of an obstetrician-gynecologist or other obstetric care provider who can monitor the progress of the pregnancy. Women who are pregnant can consult their obstetrician–gynecologist or other obstetric care provider about whether or how to accommodate their physical activeness during pregnancy and postpartum 4.

Concrete inactivity is the 4th-leading take a chance cistron for early on mortality worldwide 2. In pregnancy, physical inactivity and excessive weight gain take been recognized equally contained take a chance factors for maternal obesity and related pregnancy complications, including gestational diabetes mellitus (GDM) 5 half-dozen 7. Concerns that regular physical activity during pregnancy may cause miscarriage, poor fetal growth, musculoskeletal injury, or premature delivery have not been substantiated for women with uncomplicated pregnancies 8 9 10 xi 12. In the absence of obstetric or medical complications or contraindications, concrete activity in pregnancy is safe and desirable, and pregnant women should exist encouraged to continue or to initiate safe concrete activities Box 1 , Box 2.

Examples of Exercises That Accept Been Extensively Studied in Pregnancy and Found to Be Condom and Beneficial

• Walking

• Stationary cycling

• Aerobic exercises

• Dancing

• Resistance exercises (eg, using weights, elastic bands)

• Stretching exercises

• Hydrotherapy, water aerobics

Modified from Berghella Five, Saccone Thou. Exercise in pregnancy! Am J Obstet Gynecol 2017;216:335–7.

Benefits of Practice in Pregnancy

College incidence of:

• Vaginal delivery

Lower incidence of:

• Excessive gestational weight gain

• Gestational diabetes mellitus

• Gestational hypertensive disorders^*

• Preterm birth

• Cesarean birth

• Lower birth weight

*Defined every bit gestational hypertension or preeclampsia

Modified from Berghella V, Saccone G. Exercise in pregnancy! Am J Obstet Gynecol 2017;216:335–7.

Nearly pregnant patients can exercise. There are few maternal medical weather in which aerobic exercise is absolutely contraindicated. When questions be regarding safety of aerobic do in pregnancy, consultation with relevant specialists and subspecialists (eg, obstetrics and gynecology, maternal–fetal medicine, cardiology, pulmonology), when indicated, is advised. In women who have obstetric or medical comorbidities, practise regimens should exist individualized. Obstetrician–gynecologists and other obstetric care providers should evaluate women with medical or obstetric complications carefully before making recommendations on physical activity participation during pregnancy.

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Anatomic and Physiologic Aspects of Exercise in Pregnancy

Pregnancy results in anatomic and physiologic changes that should be considered when prescribing exercise. The most distinct changes during pregnancy are weight gain and a shift in the point of gravity that results in progressive lordosis. These changes lead to an increase in the forces across joints and the spine during weight-begetting do. Every bit a event, more than than threescore% of all significant women experience depression dorsum pain xiii. Strengthening abdominal and dorsum muscles could minimize this gamble. Blood book, heart charge per unit, stroke volume, and cardiac output ordinarily increment during pregnancy, and systemic vascular resistance decreases Table 1. These hemodynamic changes establish the circulatory reserve necessary to sustain the significant woman and fetus at rest and during exercise. Maintaining a supine position during exercise after 20 weeks of gestation may issue in decreased venous return due to aortocaval pinch from the gravid uterus, leading to hypotension, and this hemodynamic alter should exist considered when prescribing exercise modifications in pregnancy fourteen 15 16.

In pregnancy, in that location too are profound respiratory changes. Infinitesimal ventilation increases upwards to 50%, primarily as a result of the increased tidal volume. Considering of a physiologic subtract in pulmonary reserve, the ability to exercise anaerobically is impaired, and oxygen availability for aerobic exercise and increased piece of work load consistently lags. The physiologic respiratory alkalosis of pregnancy may not be sufficient to recoup for the developing metabolic acidosis of strenuous do. Decreases in subjective piece of work load and maximum exercise performance in pregnant women, peculiarly in those who are overweight or obese, limit their ability to engage in more than strenuous concrete activities 17. Aerobic training in pregnancy has been shown to increase aerobic capacity in normal weight and overweight meaning women xviii xix 20.

Temperature regulation is highly dependent on hydration and environmental conditions. During exercise, pregnant women should stay well hydrated, habiliment loose-fitting clothing, and avoid high rut and humidity to protect against heat stress, particularly during the first trimester i. Although exposure to estrus from sources such equally hot tubs, saunas, or fever has been associated with an increased risk of neural tube defects 21, exercise would not be expected to increment core body temperature into the range of concern. At least one study found no association between exercise and neural tube defects 22.

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Fetal Response to Maternal Exercise

Most of the studies addressing fetal response to maternal do have focused on fetal heart rate changes and birth weight. Studies have demonstrated minimum to moderate increases in fetal center charge per unit past 10–xxx beats per minute over the baseline during or after exercise 23 24 25 26. Three meta-analyses concluded that the differences in birth weight were minimal to none in women who exercised during pregnancy compared with controls 27 28 29. Yet, women who continued to exercise vigorously during the 3rd trimester were more than likely to deliver infants weighing 200–400 g less than comparable controls, although there was not an increased risk of fetal growth restriction 27 28 29. A cohort study that assessed umbilical artery blood menstruation, fetal heart rates, and biophysical profiles before and after strenuous exercise in the second trimester demonstrated that 30 minutes of strenuous exercise was well tolerated past women and fetuses in active and inactive pregnant women 26. More information are needed from athletes who may exert beyond the accustomed "vigorous" definition of up to 85% of chapters, and it is possible that there is an absolute level of intensity (or duration, or both) that exists, and if exceeded, could place the fetus at gamble. Individualized practise prescriptions may be warranted in pregnant athletes to define whether there is a threshold across which fetal well-beingness may be compromised 30.

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Benefits of Exercise During Pregnancy

The benefits of exercise during pregnancy are numerous Box 2 31. Regular aerobic do during pregnancy has been shown to meliorate or maintain concrete fitness 8 9 27. Observational studies of women who exercise during pregnancy have shown benefits such as decreased GDM (Odds Ratio [OR] 0.103; 95% CI, 0.013–0.803) half-dozen 32 33 34, cesarean birth (Relative Risk 0.69, 95% CI, 0.42, 0.82) 35 and operative vaginal commitment 9 35 36, and postpartum recovery time 9. Physical activeness too tin be an essential factor in the prevention of depressive disorders of women in the postpartum period 37 38. In pregnancy, greater self-reported overall physical fitness and cardiorespiratory fettle are associated with less bodily pain, lumbar and sciatic hurting, and reduced hurting disability 39. Studies are needed to explore whether improving physical fettle before and during pregnancy could decrease pain during the peripartum period.

A 2017 randomized controlled trial that included 300 overweight or obese women with uncomplicated, singleton gestations at less than 13 weeks of gestation institute that cycling exercises initiated in the first trimester and performed at least 30 minutes, 3 times per week until 37 weeks of gestation, significantly reduced the incidence of GDM, significantly reduced gestational weight proceeds at less than 25 weeks of gestation, and lowered neonatal birth weight xl. Although these investigators found no significant differences betwixt the exercise and command groups in the incidence of other outcomes, such as preterm birth, gestational hypertension, cesarean nativity, and macrosomia, all these outcomes were less frequent in the practice group.

A 2017 systematic review and meta-analysis 41 showed a significantly reduced risk of gestational hypertensive disorders, gestational hypertension, and cesarean nascence in women who performed aerobic exercise 30–60 minutes 2–7 times per week, every bit compared with women who were more than sedentary 41. Studies have shown that exercise during pregnancy can lower glucose levels in women with GDM 42 43 or help prevent preeclampsia 44. Practise has shown simply a modest decrease in overall weight proceeds (1–2 kg) in normal weight, overweight, and obese women 45 46. Another 2017 systematic review and meta-analysis 47 showed that, for overweight and obese women with a singleton pregnancy, compared with women who were more sedentary, aerobic exercise for near thirty–threescore minutes 3–7 times per week during pregnancy is associated with a reduction in the incidence of preterm birth (RR 0.62, 95% CI, 0.41–0.95) 47. Aerobic exercise in overweight and obese pregnant women also is associated with a significantly lower incidence of GDM and, therefore, should be encouraged 47. A 2016 systematic review and meta-analysis in normal-weight pregnant women with a singleton uncomplicated gestation showed that aerobic exercise for 35–90 minutes 3–4 times per week is not associated with an increased risk of preterm birth or with a reduction in mean gestational age at delivery. Practise was associated with a significantly higher incidence of vaginal commitment and a significantly lower incidence of cesarean birth, with a significantly lower incidence of GDM and hypertensive disorders 48. Finally, a 2019 systematic review and meta-analysis 49 found that in mothers with pregestational medical weather condition (chronic hypertension, type 1 diabetes and type 2 diabetes), prenatal exercise reduced the odds of cesarean nativity by 55% and did non increase the hazard of adverse maternal and neonatal outcomes (OR 0.45; 95% CI, 0.22–0.95) although findings are based on express evidence, suggesting a demand for loftier-quality investigations on exercise in this population of women.

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Recommending an Do Plan

Motivational Counseling

Pregnancy is an ideal time for beliefs modification and adoption of a healthy lifestyle because of increased motivation and frequent access to medical supervision. Patients are more likely to control weight, increase concrete activity, and improve their nutrition if their physician recommends that they do so 50. Motivational counseling tools such as the Five A's (Ask, Advise, Assess, Assist, and Accommodate), originally developed for smoking abeyance, have been used successfully for diet and exercise counseling 51 52. Obstetrician–gynecologists and other obstetric care providers tin can consider adopting the Five A's arroyo for women with uncomplicated pregnancies who have no contraindications to exercise.

Prescribing an Individualized Exercise Program

The principles of exercise prescription for pregnant women do not differ from those for the general population 4. A thorough clinical evaluation should be conducted earlier recommending an exercise program to ensure that a patient does not have a medical reason to avoid exercise. An exercise plan that leads to an eventual goal of moderate-intensity exercise for at least 20–thirty minutes per day on most or all days of the week should be developed with the patient and adjusted as medically indicated.

Considering blunted and normal heart-rate responses to exercise accept been reported in pregnant women, the utilize of ratings of perceived exertion may be a more effective means to monitor exercise intensity during pregnancy than heart-rate parameters 53. For moderate-intensity exercise, ratings of perceived exertion should be 13–14 (somewhat hard) on the Borg ratings of perceived exertion scale Table 2. Using the "talk test" is another way to measure exertion: every bit long equally a adult female tin can deport on a conversation while exercising, she probable is not overexerting herself 54. Women should be advised to remain well hydrated, avoid long periods of lying apartment on their backs, and stop exercising if they have any of the warning signs listed in Box three .

Warning Signs to Discontinue Do While Meaning

• Vaginal bleeding

• Abdominal hurting

• Regular painful contractions

• Amniotic fluid leakage

• Dyspnea before exertion

• Dizziness

• Headache

• Breast pain

• Musculus weakness affecting residue

• Calf hurting or swelling

Pregnant women who were sedentary before pregnancy should follow a more gradual progression of do. Although an upper level of safe exercise intensity has not been established, women who were regular exercisers earlier pregnancy and who have simple, healthy pregnancies should be able to engage in high-intensity practice programs, such as jogging and aerobics, with no agin effects. High-intensity or prolonged practise in excess of 45 minutes tin can lead to hypoglycemia; therefore, adequate caloric intake before practise, or limiting the intensity or length of the practice session, is essential to minimize this hazard 55.

Prolonged exercise should be performed in a thermoneutral environment or in controlled environmental conditions (facilities with air-conditioning) and meaning women should avoid prolonged exposure to estrus 56 and pay close attention to proper hydration and caloric intake. In studies of pregnant women who exercised in which concrete activity was cocky-paced in a temperature-controlled environment, cadre torso temperatures rose less than 1.five°C over xxx minutes and stayed within safety limits 31. Table 3 lists suggestions for an exercise programme in pregnancy 31. Finally, although physical activity and dehydration in pregnancy accept been associated with a pocket-sized increase in uterine contractions 57, a 2016 systematic review and meta-analysis in normal-weight pregnant women with singleton uncomplicated gestations demonstrated that exercise for 35–ninety minutes 3–four times per calendar week is not associated with an increased run a risk of preterm birth or with a reduction in hateful gestational age at delivery 48.

Types of Exercises

Box 1 lists examples of rubber exercises in pregnancy. Women with unproblematic pregnancies should be encouraged to engage in aerobic and strength-conditioning exercises before, during, and afterward pregnancy. Contact activities with high risk of abdominal trauma or imbalance should be avoided. Scuba diving should be avoided in pregnancy because of the inability of the fetal pulmonary apportionment to filter chimera germination 58. Women living at sea level were able to tolerate physical action up to altitudes of 6,000 feet, suggesting this altitude is safety in pregnancy 59, although more research is needed. Women who reside at higher altitudes may be able to exercise safely at altitudes college than vi,000 feet.

In those instances in which women feel low-back pain, practise in h2o is an alternative 60. A report of the apparent weight reduction during water immersion in a 3rd-trimester pregnant woman measured a hateful of 82.9% of torso weight, a reduction that lowers the maternal osteoarticular load due to buoyancy 61. There may be additional benefits of aquatic practice as well. A randomized controlled trial of an aquatic physical do program during pregnancy consisting of three threescore-infinitesimal exercises demonstrated a greater rate of intact perineum after childbirth (OR 13.54, 95% CI, 2.75–66.56) 62.

Special Populations

Pregnant Women With Obesity

Significant women with obesity should be encouraged to engage in a healthy lifestyle modification in pregnancy that includes concrete activities and judicious diets v. Women should commencement with depression-intensity, curt periods of exercise and gradually increase the flow or intensity of do as they are able. In recent studies examining the effects of exercise among pregnant women with obesity, women assigned to exercise demonstrated modest reductions in weight gain and no agin outcomes 45 63.

Athletes

Vigorous-intensity exercise completed into the third trimester appears to be safe for almost healthy pregnancies. Further research is needed on the effects of vigorous-intensity practice in the kickoff and second trimesters and of practice intensity exceeding 90% of maximum heart rate 64. Competitive athletes require frequent and close supervision considering they tend to maintain a more strenuous training schedule throughout pregnancy and resume high-intensity training postpartum sooner than other women. Such athletes should pay particular attending to avoiding hyperthermia, maintaining proper hydration, and sustaining adequate caloric intake to prevent weight loss, which may adversely affect fetal growth.

An aristocracy athlete tin exist divers generally as an athlete with several years of experience in a particular sport or sports who has competed successfully against other high level performers and trains twelvemonth-round at a high level; an elite athlete more often than not trains at least 5 days per calendar week, averaging close to 2 hours per day throughout the yr 30. In addition to aerobic training, elite athletes in near sports besides participate in resistance preparation to increase muscular forcefulness and endurance; however, this preparation was non considered a safe activity in early guidelines for exercise during pregnancy because of potential injury and possible fetal heart decelerations resulting from Valsalva maneuvers. Consequently, there is sparse literature on this topic 30. It is prudent for elite athletes who wish to keep strenuous activity during pregnancy to have a clear understanding of the risks, to obtain approval from their health care providers, and to consider decreasing resistance load compared with prepregnant weather condition. High-impact activities with increased run a risk of blunt trauma should exist avoided, and information technology also is important that the pregnant elite athlete avoid overheating when performing their sport or participating in intense training 30.

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Activity Restriction

Several reviews have determined that there is no apparent evidence to prescribe bed rest in pregnancy for the prevention of preterm labor, and information technology should not exist routinely recommended 65 66. Patients prescribed prolonged bed rest or restricted concrete activity are at risk of venous thromboembolism, os demineralization, and deconditioning. In that location are no studies documenting an improvement in outcomes in women at risk for preterm birth who are placed on activity brake, including bed residue, and in that location are multiple studies documenting untoward effects of routine activity restriction on the mother and family, including negative psychosocial effects. Activity restriction should not be prescribed routinely every bit a treatment to reduce preterm birth 67. Additionally, in that location is no evidence that bed rest reduces preeclampsia take chances, and information technology should non exist routinely recommended for the primary prevention of preeclampsia and its complications 68.

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Occupational Physical Activity

The prove regarding a possible clan between fetal–maternal wellness outcomes and occupational physical action is mixed and limited. A meta-analysis based on 62 reports assessed the testify relating preterm delivery, low nascence weight, small-scale for gestational historic period, preeclampsia, and gestational hypertension to five occupational exposures (work hours, shift work, lifting, standing, and physical work load) 69. Although the analysis was limited by the heterogeneity of exposure definitions, peculiarly for lifting and heavy work load, most of the estimates of risk pointed to minor or nix furnishings. In contrast, a cohort written report of more 62,000 Danish women reported a dose–response human relationship between full daily burden lifted and preterm birth with loads more than i,000 kg per day 70. In this study, lifting heavy loads (greater than xx kg) more 10 times per day was associated with an increased risk of preterm birth.

The National Institute for Occupational Safety and Health uses an equation that determines the maximum recommended weight limit for lifting that would be acceptable to 90% of healthy women 71. This equation has been used to define recommended weight limits for a broad range of lifting patterns for pregnant women, as well as lifting conditions that pose a higher risk of musculoskeletal injury 72 Effigy 1. Obstetrician–gynecologists and other obstetric intendance providers tin can apply their best clinical judgment to determine a recommended plan for the patient. This plan may include a formal request for an occupational wellness professional to perform an analysis to determine maximum weight limits based on bodily lifting condition or assistance with writing advisable letters to employers to help obtain accommodations 73.

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Exercise in the Postpartum Period

Several reports indicate that women'due south level of participation in practice programs diminishes after childbirth, frequently leading to overweight and obesity 74 75. The postpartum menses is an opportune fourth dimension for obstetrician–gynecologists and other obstetric care providers to recommend and reinforce a healthy lifestyle. Resuming do or incorporating new do routines afterward commitment is important in supporting lifelong good for you habits. Practise routines may be resumed gradually after pregnancy as soon every bit medically condom, depending on the mode of delivery (vaginal or cesarean birth) and the presence or absenteeism of medical or surgical complications. Some women are capable of resuming physical activities within days of delivery. Pelvic floor exercises can be initiated in the immediate postpartum period. Abdominal strengthening exercises, including abdominal crunch exercises and the cartoon-in practise, a maneuver that increases abdominal pressure by pulling in the abdominal wall muscles, have been shown to subtract the incidence of diastasis recti abdominus and decrease the inter-rectus distance in women who gave birth vaginally or past cesarean birth 76 77.

Regular aerobic do in lactating women has been shown to better maternal cardiovascular fettle without affecting milk product, limerick, or infant growth 78. Women who are lactating should consider feeding their infants or expressing milk before exercising to avoid discomfort of engorged breasts. They also should ensure adequate hydration earlier commencing physical activity.

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Conclusion

Concrete activity and practice in pregnancy are associated with minimal risks and have been shown to benefit virtually women, although some modification to do routines may be necessary considering of normal anatomic and physiologic changes and fetal requirements. In the absence of obstetric or medical complications or contraindications, physical activity in pregnancy is safe and desirable, and pregnant women should be encouraged to go along or to initiate safe physical activities. Obstetrician–gynecologists and other obstetric care providers should evaluate women with medical or obstetric complications carefully before making recommendations on physical action participation during pregnancy. Although the evidence is limited, exercise results in benefits to pregnancy outcomes, and there is no testify of harm when do is non contraindicated. Concrete activity and exercise during pregnancy promote concrete fettle and may forbid excessive gestational weight gain. Exercise may reduce the risk of gestational diabetes, preeclampsia, and cesarean birth. Additional research is needed to study the furnishings of exercise on pregnancy-specific weather condition and outcomes and to clarify further effective behavioral counseling methods and the optimal type, frequency, and intensity of exercise. Similar inquiry is needed to create an improved evidence base concerning the effects of occupational physical activity on maternal–fetal health.

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Source: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/04/physical-activity-and-exercise-during-pregnancy-and-the-postpartum-period

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