what are the best exercises for pregnant women to help with fetal future development

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Number 804 (Replaces Commission Opinion Number 650, Dec 2015)

Committee on Obstetric Practice

This Committee Stance was developed past the Commission on Obstetric Practice with the assistance of committee members Meredith L. Birsner, MD; and Cynthia Gyamfi-Bannerman, Dr., MSc.

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Abstract: Exercise, defined as concrete activity consisting of planned, structured, and repetitive actual movements washed to ameliorate one or more than components of physical fitness, is an essential element of a healthy lifestyle, and obstetrician–gynecologists and other obstetric care providers should encourage their patients to proceed or to commence practice as an important component of optimal wellness. Women who habitually engaged in vigorous-intensity aerobic activity or who were physically active before pregnancy tin can proceed these activities during pregnancy and the postpartum menstruum. Observational studies of women who practice during pregnancy have shown benefits such every bit decreased gestational diabetes mellitus, cesarean birth 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 activity and exercise in pregnancy are associated with minimal risks and accept been shown to benefit nigh women, although some modification to practice routines may exist necessary considering of normal anatomic and physiologic changes and fetal requirements. In the absence of obstetric or medical complications or contraindications, concrete activity in pregnancy is safe and desirable, and meaning women should exist encouraged to continue or to initiate safe physical activities. This document has been revised to comprise recent prove regarding the benefits and risks of physical activeness and do during pregnancy and the postpartum menstruum.

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Recommendations

Regular physical action in all phases of life, including pregnancy, promotes health benefits. Pregnancy is an ideal fourth dimension for maintaining or adopting a healthy lifestyle and the American College of Obstetricians and Gynecologists makes the following recommendations:

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

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

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

• Obstetrician–gynecologists and other obstetric intendance providers should evaluate women with medical or obstetric complications carefully before making recommendations on concrete activity participation during pregnancy. Activity restriction should not exist prescribed routinely equally a treatment to reduce preterm nascency.

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

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Introduction

This certificate has been revised to incorporate recent evidence regarding the benefits and risks of concrete activity and exercise during pregnancy and the postpartum menstruation. Physical activity , defined as whatsoever bodily movement produced by 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 healthy lifestyle (eg, exercise, good nutrition, nonsmoking) should be encouraged to maintain those good for you habits. Women who practice non accept good for you lifestyles should exist encouraged to view the prepregnancy flow and pregnancy as opportunities to embrace healthier routines. Do , defined as concrete activity consisting of planned, structured, and repetitive actual movements done to ameliorate ane or more components of concrete fitness i, is an essential chemical element of a healthy lifestyle, and obstetrician–gynecologists and other obstetric care providers should encourage their patients to proceed or to commence exercise as an of import component of optimal wellness.

The World Health Arrangement and the American Higher of Sports Medicine have issued bear witness-based recommendations indicating that the beneficial effects of exercise in about adults are indisputable and that the benefits far outweigh the risks 2 3.

The 2018 update to the U.S. Department of Health and Man Services Concrete Action Guidelines for Americans reinforces prior recommendations of at to the lowest degree 150 minutes of moderate intensity aerobic activeness per calendar week during pregnancy and the postpartum period 4. This activity should exist spread throughout the week. The guidelines suggest that women who habitually engaged in vigorous-intensity aerobic activity or who were physically active before pregnancy can keep these activities during pregnancy and the postpartum period. Additionally, women who are pregnant should be under the intendance of an obstetrician-gynecologist or other obstetric care provider who tin monitor the progress of the pregnancy. Women who are pregnant tin can consult their obstetrician–gynecologist or other obstetric intendance provider about whether or how to arrange their physical activity during pregnancy and postpartum four.

Physical inactivity is the 4th-leading risk factor for early mortality worldwide two. In pregnancy, physical inactivity and excessive weight gain accept 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 commitment accept non been substantiated for women with elementary pregnancies 8 9 10 11 12. In the absence of obstetric or medical complications or contraindications, physical action in pregnancy is safe and desirable, and pregnant women should be encouraged to proceed or to initiate rubber concrete activities Box ane , Box two.

Examples of Exercises That Have Been Extensively Studied in Pregnancy and Found to Be Safe and Beneficial

• Walking

• Stationary cycling

• Aerobic exercises

• Dancing

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

• Stretching exercises

• Hydrotherapy, water aerobics

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

Benefits of Practise in Pregnancy

Higher incidence of:

• Vaginal delivery

Lower incidence of:

• Excessive gestational weight gain

• Gestational diabetes mellitus

• Gestational hypertensive disorders^*

• Preterm birth

• Cesarean nascency

• Lower nascency weight

*Defined equally gestational hypertension or preeclampsia

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

Most pregnant patients can exercise. At that place are few maternal medical conditions in which aerobic do is absolutely contraindicated. When questions be regarding rubber of aerobic practise in pregnancy, consultation with relevant specialists and subspecialists (eg, obstetrics and gynecology, maternal–fetal medicine, cardiology, pulmonology), when indicated, is brash. In women who have obstetric or medical comorbidities, exercise regimens should be individualized. Obstetrician–gynecologists and other obstetric intendance providers should evaluate women with medical or obstetric complications advisedly 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 practise. The about 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-bearing exercise. As a result, more than 60% of all pregnant women feel depression back pain 13. Strengthening intestinal and back muscles could minimize this risk. Blood book, heart rate, stroke volume, and cardiac output usually increment during pregnancy, and systemic vascular resistance decreases Table ane. These hemodynamic changes establish the circulatory reserve necessary to sustain the pregnant adult female and fetus at rest and during do. Maintaining a supine position during exercise later on xx weeks of gestation may result in decreased venous return due to aortocaval compression from the gravid uterus, leading to hypotension, and this hemodynamic change should be considered when prescribing practise modifications in pregnancy xiv 15 16.

In pregnancy, there also are profound respiratory changes. Infinitesimal ventilation increases up to 50%, primarily as a consequence of the increased tidal volume. Considering of a physiologic subtract in pulmonary reserve, the ability to practice anaerobically is impaired, and oxygen availability for aerobic practise and increased work load consistently lags. The physiologic respiratory alkalosis of pregnancy may non exist sufficient to compensate for the developing metabolic acidosis of strenuous practise. Decreases in subjective work load and maximum exercise functioning in pregnant women, particularly in those who are overweight or obese, limit their ability to appoint in more strenuous concrete activities 17. Aerobic training in pregnancy has been shown to increase aerobic capacity in normal weight and overweight meaning women 18 19 20.

Temperature regulation is highly dependent on hydration and environmental conditions. During exercise, pregnant women should stay well hydrated, wear loose-plumbing fixtures clothing, and avoid high estrus and humidity to protect against estrus stress, specially during the first trimester one. Although exposure to heat from sources such equally hot tubs, saunas, or fever has been associated with an increased gamble of neural tube defects 21, exercise would non be expected to increase core body temperature into the range of concern. At to the lowest degree i study establish no clan between practice and neural tube defects 22.

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Fetal Response to Maternal Practise

Most of the studies addressing fetal response to maternal practise have focused on fetal heart rate changes and birth weight. Studies have demonstrated minimum to moderate increases in fetal heart rate by 10–30 beats per infinitesimal 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. However, women who continued to do vigorously during the third trimester were more likely to deliver infants weighing 200–400 thousand less than comparable controls, although there was not an increased gamble of fetal growth restriction 27 28 29. A cohort report that assessed umbilical artery blood catamenia, fetal heart rates, and biophysical profiles before and after strenuous practise in the 2nd trimester demonstrated that 30 minutes of strenuous exercise was well tolerated past women and fetuses in active and inactive significant women 26. More data are needed from athletes who may exert beyond the accepted "vigorous" definition of up to 85% of chapters, and information technology is possible that there is an absolute level of intensity (or duration, or both) that exists, and if exceeded, could place the fetus at risk. Individualized exercise prescriptions may be warranted in significant athletes to define whether in that location is a threshold beyond which fetal well-being may exist compromised xxx.

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Benefits of Exercise During Pregnancy

The benefits of exercise during pregnancy are numerous Box 2 31. Regular aerobic practise during pregnancy has been shown to better or maintain physical fitness 8 9 27. Observational studies of women who exercise during pregnancy accept shown benefits such as decreased GDM (Odds Ratio [OR] 0.103; 95% CI, 0.013–0.803) 6 32 33 34, cesarean birth (Relative Adventure 0.69, 95% CI, 0.42, 0.82) 35 and operative vaginal delivery 9 35 36, and postpartum recovery fourth dimension nine. Concrete activity also can be an essential gene 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 actual pain, lumbar and sciatic pain, and reduced pain disability 39. Studies are needed to explore whether improving physical fettle before and during pregnancy could subtract pain during the peripartum period.

A 2017 randomized controlled trial that included 300 overweight or obese women with elementary, singleton gestations at less than xiii weeks of gestation plant that cycling exercises initiated in the beginning trimester and performed at least 30 minutes, three times per week until 37 weeks of gestation, significantly reduced the incidence of GDM, significantly reduced gestational weight gain at less than 25 weeks of gestation, and lowered neonatal birth weight twoscore. Although these investigators found no meaning differences between the practice and control groups in the incidence of other outcomes, such as preterm nascence, gestational hypertension, cesarean birth, and macrosomia, all these outcomes were less frequent in the practice grouping.

A 2017 systematic review and meta-analysis 41 showed a significantly reduced risk of gestational hypertensive disorders, gestational hypertension, and cesarean birth in women who performed aerobic exercise 30–60 minutes 2–vii times per calendar week, as compared with women who were more sedentary 41. Studies have shown that practice during pregnancy can lower glucose levels in women with GDM 42 43 or help prevent preeclampsia 44. Exercise has shown just a modest subtract in overall weight gain (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 than sedentary, aerobic practice for about 30–lx 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 practice in overweight and obese meaning women also is associated with a significantly lower incidence of GDM and, therefore, should exist encouraged 47. A 2016 systematic review and meta-analysis in normal-weight meaning women with a singleton uncomplicated gestation showed that aerobic exercise for 35–90 minutes 3–four times per week is not associated with an increased risk of preterm birth or with a reduction in hateful gestational age at delivery. Practice was associated with a significantly higher incidence of vaginal delivery 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 not increase the run a risk of adverse maternal and neonatal outcomes (OR 0.45; 95% CI, 0.22–0.95) although findings are based on limited bear witness, suggesting a need for high-quality investigations on exercise in this population of women.

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Recommending an Exercise Program

Motivational Counseling

Pregnancy is an ideal fourth dimension for behavior modification and adoption of a good for you lifestyle because of increased motivation and frequent access to medical supervision. Patients are more likely to control weight, increase physical activeness, and improve their diet if their physician recommends that they do so 50. Motivational counseling tools such as the Five A's (Ask, Suggest, Assess, Assist, and Arrange), originally adult for smoking cessation, have been used successfully for diet and exercise counseling 51 52. Obstetrician–gynecologists and other obstetric care providers 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 do prescription for pregnant women practice not differ from those for the general population iv. 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 practise. An exercise program that leads to an eventual goal of moderate-intensity practise for at least twenty–30 minutes per mean solar day on most or all days of the week should be developed with the patient and adjusted every bit medically indicated.

Because blunted and normal centre-charge per unit responses to exercise have been reported in significant women, the use of ratings of perceived exertion may be a more effective means to monitor exercise intensity during pregnancy than center-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 fashion to measure exertion: as long every bit a woman tin can carry on a chat while exercising, she likely is not overexerting herself 54. Women should exist advised to remain well hydrated, avoid long periods of lying flat on their backs, and stop exercising if they take whatsoever of the warning signs listed in Box 3 .

Warning Signs to Discontinue Do While Significant

• Vaginal bleeding

• Abdominal pain

• Regular painful contractions

• Amniotic fluid leakage

• Dyspnea before exertion

• Dizziness

• Headache

• Chest pain

• Muscle weakness affecting residuum

• Dogie pain or swelling

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

Prolonged do should be performed in a thermoneutral environment or in controlled environmental weather condition (facilities with air-conditioning) and meaning women should avoid prolonged exposure to heat 56 and pay close attention to proper hydration and caloric intake. In studies of pregnant women who exercised in which physical activity was self-paced in a temperature-controlled environs, cadre torso temperatures rose less than 1.5°C over 30 minutes and stayed inside safe limits 31. Table three lists suggestions for an practise programme in pregnancy 31. Finally, although physical activity and dehydration in pregnancy accept been associated with a small 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–xc minutes 3–4 times per week is non associated with an increased risk of preterm nativity or with a reduction in mean gestational age at delivery 48.

Types of Exercises

Box 1 lists examples of safe exercises in pregnancy. Women with uncomplicated pregnancies should be encouraged to engage in aerobic and strength-conditioning exercises earlier, during, and after pregnancy. Contact activities with high take a chance of intestinal trauma or imbalance should be avoided. Scuba diving should exist avoided in pregnancy because of the inability of the fetal pulmonary circulation to filter bubble formation 58. Women living at ocean level were able to tolerate physical action up to altitudes of 6,000 anxiety, suggesting this altitude is rubber in pregnancy 59, although more inquiry is needed. Women who reside at higher altitudes may be able to practise safely at altitudes higher than vi,000 feet.

In those instances in which women experience depression-back pain, exercise in water is an culling lx. A study of the apparent weight reduction during water immersion in a third-trimester pregnant woman measured a mean of 82.9% of body weight, a reduction that lowers the maternal osteoarticular load due to buoyancy 61. There may be additional benefits of aquatic exercise also. A randomized controlled trial of an aquatic concrete practise program during pregnancy consisting of three threescore-minute exercises demonstrated a greater rate of intact perineum after childbirth (OR xiii.54, 95% CI, two.75–66.56) 62.

Special Populations

Meaning Women With Obesity

Pregnant women with obesity should be encouraged to engage in a healthy lifestyle modification in pregnancy that includes concrete activities and judicious diets 5. Women should start with depression-intensity, brusk periods of exercise and gradually increase the menstruation or intensity of practice as they are able. In recent studies examining the effects of practise amongst pregnant women with obesity, women assigned to exercise demonstrated pocket-sized reductions in weight gain and no adverse outcomes 45 63.

Athletes

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

An elite athlete can exist defined generally as an athlete with several years of feel in a item sport or sports who has competed successfully confronting other high level performers and trains year-round at a loftier level; an elite athlete by and large trains at least 5 days per week, averaging close to 2 hours per day throughout the year thirty. In improver to aerobic training, elite athletes in about sports likewise participate in resistance preparation to increase muscular forcefulness and endurance; still, this grooming was not considered a safe activity in early guidelines for exercise during pregnancy considering of potential injury and possible fetal heart decelerations resulting from Valsalva maneuvers. Consequently, there is sparse literature on this topic xxx. It is prudent for aristocracy athletes who wish to continue strenuous action during pregnancy to accept a clear understanding of the risks, to obtain approval from their wellness care providers, and to consider decreasing resistance load compared with prepregnant conditions. High-impact activities with increased risk of blunt trauma should be avoided, and information technology also is important that the significant elite athlete avoid overheating when performing their sport or participating in intense training xxx.

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Activity Brake

Several reviews accept determined that at that place is no credible prove to prescribe bed residue in pregnancy for the prevention of preterm labor, and information technology should not be routinely recommended 65 66. Patients prescribed prolonged bed residuum or restricted physical activity are at adventure of venous thromboembolism, bone demineralization, and deconditioning. There are no studies documenting an comeback in outcomes in women at risk for preterm nativity who are placed on activity restriction, including bed rest, and there are multiple studies documenting untoward furnishings of routine activity restriction on the mother and family, including negative psychosocial effects. Activity restriction should not be prescribed routinely equally a treatment to reduce preterm nascence 67. Additionally, there is no evidence that bed rest reduces preeclampsia gamble, and it should non exist routinely recommended for the main prevention of preeclampsia and its complications 68.

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Occupational Physical Activeness

The show regarding a possible association between fetal–maternal health outcomes and occupational concrete activity is mixed and limited. A meta-assay based on 62 reports assessed the testify relating preterm delivery, low birth weight, small for gestational age, preeclampsia, and gestational hypertension to five occupational exposures (work hours, shift work, lifting, continuing, and concrete piece of work load) 69. Although the analysis was express by the heterogeneity of exposure definitions, especially for lifting and heavy work load, near of the estimates of adventure pointed to pocket-sized or nix effects. In contrast, a cohort written report of more than 62,000 Danish women reported a dose–response human relationship between total daily burden lifted and preterm birth with loads more than than 1,000 kg per day 70. In this report, lifting heavy loads (greater than 20 kg) more 10 times per twenty-four hour period was associated with an increased gamble of preterm birth.

The National Institute for Occupational Condom and Wellness uses an equation that determines the maximum recommended weight limit for lifting that would be acceptable to ninety% of salubrious women 71. This equation has been used to define recommended weight limits for a wide range of lifting patterns for pregnant women, as well as lifting conditions that pose a higher chance of musculoskeletal injury 72 Figure 1. Obstetrician–gynecologists and other obstetric intendance providers can use their best clinical judgment to determine a recommended plan for the patient. This plan may include a formal asking for an occupational health professional person to perform an analysis to determine maximum weight limits based on actual lifting condition or aid with writing appropriate letters to employers to help obtain accommodations 73.

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Exercise in the Postpartum Period

Several reports indicate that women'southward level of participation in exercise programs diminishes later childbirth, oftentimes leading to overweight and obesity 74 75. The postpartum menses is an opportune time for obstetrician–gynecologists and other obstetric care providers to recommend and reinforce a good for you lifestyle. Resuming exercise or incorporating new exercise routines after delivery is of import in supporting lifelong healthy habits. Exercise routines may exist resumed gradually after pregnancy as soon every bit medically safe, depending on the style of commitment (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 tin can exist initiated in the immediate postpartum period. Intestinal strengthening exercises, including abdominal crunch exercises and the drawing-in exercise, a maneuver that increases abdominal pressure by pulling in the abdominal wall muscles, have been shown to decrease the incidence of diastasis recti abdominus and decrease the inter-rectus distance in women who gave birth vaginally or by cesarean nativity 76 77.

Regular aerobic exercise in lactating women has been shown to improve maternal cardiovascular fitness without affecting milk production, composition, 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 before commencing physical activity.

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Conclusion

Physical activity and exercise in pregnancy are associated with minimal risks and have been shown to benefit well-nigh women, although some modification to exercise routines may exist necessary because of normal anatomic and physiologic changes and fetal requirements. In the absenteeism 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 rubber 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 bear witness is limited, exercise results in benefits to pregnancy outcomes, and in that location is no evidence of harm when exercise is non contraindicated. Concrete activity and exercise during pregnancy promote physical fitness and may preclude excessive gestational weight gain. Practice may reduce the gamble of gestational diabetes, preeclampsia, and cesarean birth. Additional research is needed to report the effects of exercise on pregnancy-specific conditions and outcomes and to analyze further effective behavioral counseling methods and the optimal type, frequency, and intensity of do. Similar research 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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