Abstract
Objective
The objective is to provide guidance for pregnant women, and obstetric care and exercise
professionals, on prenatal physical activity.
Outcomes
The outcomes evaluated were maternal, fetal, or neonatal morbidity or fetal mortality
during and following pregnancy.
Evidence
Literature was retrieved through searches of Medline, EMBASE, PsycINFO, Cochrane Database
of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus and
Web of Science Core Collection, CINAHL Plus with Full-text, Child Development & Adolescent
Studies, ERIC, Sport Discus, ClinicalTrials.gov, and the Trip Database from database
inception up to January 6, 2017. Primary studies of any design were eligible, except
case studies. Results were limited to English, Spanish, or French language materials.
Articles related to maternal physical activity during pregnancy reporting on maternal,
fetal, or neonatal morbidity or fetal mortality were eligible for inclusion. The quality
of evidence was rated using the Grading of Recommendations Assessment, Development,
and Evaluation (GRADE) methodology.
Values
The Guidelines Consensus Panel solicited feedback from end-users (obstetric care providers, exercise professionals,
researchers, policy organizations, and pregnant and postpartum women). The development
of this guideline followed the Appraisal of Guidelines for Research Evaluation (AGREE)
II instrument.
Benefits, harms, and costs
The benefits of prenatal physical activity are moderate, and no harms were identified;
therefore, the difference between desirable and undesirable consequences (net benefit)
is expected to be moderate. The majority of stakeholders and end-users indicated that
following these recommendations would be feasible, acceptable, and equitable. Following
these recommendations is likely to require minimal resources from both individual
and health systems perspectives.
Preamble
This guideline provide evidence-based recommendations regarding physical activity
throughout pregnancy in the promotion of maternal, fetal, and neonatal health. In
the absence of contraindications (see later for a detailed list), following this guideline
is associated with: (1) fewer newborn complications (i.e., large for gestational age);
and (2) maternal health benefits (i.e., decreased risk of preeclampsia, gestational
hypertension, gestational diabetes, Caesarean section, instrumental delivery, urinary
incontinence, excessive gestational weight gain, and depression; improved blood glucose;
decreased total gestational weight gain; and decreased severity of depressive symptoms
and lumbopelvic pain). Physical activity is not associated with miscarriage, stillbirth,
neonatal death, preterm birth, preterm/prelabour rupture of membranes, neonatal hypoglycemia,
low birth weight, birth defects, induction of labour, or birth complications. In general,
more physical activity (frequency, duration, and/or volume) is associated with greater
benefits. However, evidence was not identified regarding the safety or additional
benefit of exercising at levels significantly above the recommendations. Prenatal
physical activity should be considered a front-line therapy for reducing the risk
of pregnancy complications and enhancing maternal physical and mental health. For
pregnant women not currently meeting this guideline, a progressive adjustment toward
them is recommended. Previously active women may continue physical activity throughout
pregnancy. Women may need to modify physical activity as pregnancy progresses. There
may be periods when following the guideline is not possible due to fatigue and/or
discomforts of pregnancy; women are encouraged to do what they can and to return to
following the recommendations when they are able. This guideline were informed by
an extensive systematic review of the literature, expert opinion, end-user consultation
and considerations of feasibility, acceptability, costs, and equity.
Recommendations
The specific recommendations in this 2019 Canadian Guideline for Physical Activity Throughout Pregnancy are provided below with corresponding statements indicating the quality of the evidence
informing the recommendations and the strength of the recommendations (explanations
follow).
- 1All women without contraindication should be physically active throughout pregnancy (strong recommendation, moderate quality evidence). Specific subgroups were examined:
- aWomen who were previously inactive (strong recommendation, moderate quality evidence).
- bWomen diagnosed with gestational diabetes mellitus (weak recommendation,a low quality evidence).
- cWomen categorized as overweight or obese (pre-pregnancy body mass index ≥25 kg/m2) (strong recommendation,b low quality evidence).
- 2Pregnant women should accumulate at least 150 minutes of moderate-intensityc physical activity each week to achieve clinically meaningful health benefits and reductions in pregnancy complications (strong recommendation, moderate quality evidence).
- 3Physical activity should be accumulated over a minimum of 3 days per week; however, being active every day is encouraged (strong recommendation, moderate quality evidence).
- 4Pregnant women should incorporate a variety of aerobic exercise and resistance training activities to achieve greater benefits. Adding yoga and/or gentle stretching may also be beneficial (strong recommendation, high quality evidence).
- 5Pelvic floor muscle training (e.g., Kegel exercises) may be performed on a daily basis to reduce the risk of urinary incontinence. Instruction in proper technique is recommended to obtain optimal benefits (weak recommendation,d low quality evidence).
- 6Pregnant women who experience light-headedness, experience nausea, or feel unwell when they exercise flat on their back should modify their exercise position to avoid the supine position (weak recommendation,e very low quality evidence).
Contraindications
All pregnant women can participate in physical activity throughout pregnancy with
the exception of those who have contraindications (listed below). Women with absolute
contraindications may continue their usual activities of daily living but should not
participate in more strenuous activities. Women with relative contraindications should
discuss the advantages and disadvantages of moderate-to-vigorous intensity physical
activity with their obstetric care provider prior to participation.
Absolute contraindications to exercise are the following:
-
- •Ruptured membranes
- •Premature labour
- •Unexplained persistent vaginal bleeding
- •Placenta previa after 28 weeks’ gestation
- •Preeclampsia
- •Incompetent cervix
- •Intrauterine growth restriction
- •High-order multiple pregnancy (e.g., triplets)
- •Uncontrolled type 1 diabetes
- •Uncontrolled hypertension
- •Uncontrolled thyroid disease
- •Other serious cardiovascular, respiratory, or systemic disorder
- •
Relative contraindications to exercise are the following:
-
- •Recurrent pregnancy loss
- •Gestational hypertension
- •A history of spontaneous preterm birth
- •Mild/moderate cardiovascular or respiratory disease
- •Symptomatic anemia
- •Malnutrition
- •Eating disorder
- •Twin pregnancy after the 28th week
- •Other significant medical conditions
- •
Strength of the Recommendations
The GRADE system was utilized to grade the strength of the recommendations. Recommendations
are rated as strong or weak based on the: (1) balance between benefits and harms;
(2) overall quality of the evidence; (3) importance of outcomes (i.e., values and
preferences of pregnant women); (4) use of resources (i.e., cost); (5) impact on health
equity; (6) feasibility, and (7) acceptability.
Strong recommendation: Most or all pregnant women will be best served by the recommended course of action.
Weak recommendation: Not all pregnant women will be best served by the recommended course of action; there
is a need to consider other factors such as the individual's circumstances, preferences,
values, resources available, or setting. Consultation with an obstetric care provider
may assist in decision-making.
Quality of the Evidence
The quality of the evidence refers to the level of confidence in the evidence and
ranges from very low to high.
High quality: The Guideline Consensus Panel is very confident that the estimated effect of physical activity on the health outcome
is close to the true effect.
Moderate quality: The Guideline Consensus Panel is moderately confident in the estimated effect of physical activity on the health
outcome; the estimate of the effect is likely to be close to the true effect, but
there is a possibility that it is substantially different.
Low quality: The Guideline Consensus Panel's confidence in the estimated effect of physical activity on the health outcome is
limited; the estimate of the effect may be substantially different from the true effect.
Very low quality: The Guideline Consensus Panel has very little confidence in the estimated effect of physical activity on the health
outcome; the estimate of the effect is likely to be substantially different from the
true effect.
aThis was a weak recommendation because the quality of evidence was low, and the net
benefit between women who were physically active and those who were not was small.
bThis was a strong recommendation because, despite low quality evidence supporting
physical activity during pregnancy for women categorized as overweight or obese, there
was evidence from randomized controlled trials demonstrating an improvement in gestational
weight gain and blood glucose.
cModerate-intensity physical activity is intense enough to noticeably increase heart
rate; a person can talk but not sing during activities of this intensity. Examples
of moderate-intensity physical activity include brisk walking, water aerobics, stationary
cycling (moderate effort), resistance training, carrying moderate loads, and household
chores (e.g., gardening, washing windows).
dThis was a weak recommendation because urinary incontinence was was not rated as a
“critical” outcome and the evidence was low quality.
eThis was a weak recommendation because: (1) the quality of evidence was very low;
and (2) although harms were investigated there was limited available information to
inform the balance of benefits and harms. This recommendation was primarily based
on expert opinion.
Abbreviations:
AGREE (Appraisal of Guidelines for Research and Evaluation (AGREE) II), CSEP (Canadian Society for Exercise Physiology), GDM (gestational diabetes mellitus), GRADE (Grading of Recommendations Assessment, Development and Evaluation), PFMT (pelvic floor muscle training), RCT (randomized controlled trial), SOGC (Society of Obstetricians and Gynaecologists of Canada)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: October 05, 2018
No. XXX, Month YearFootnotes
The following organizations have reviewed this document and endorse the Joint SOGC/CSEP Canadian Guidelines for Physical Activity throughout Pregnancy:• Alberta Health Services – Healthy Families and Children • Canadian Academy of Sports Medicine • Canadian Association of Midwives • College of Family Physicians of Canada • Directorate for Chief Medical Officer and Chief Scientist Office of Scotland • Exercise is Medicine Canada • Ontario Public Health Association • ParticipACTION • Perinatal Services BC • Sociedad Espanola de Ginecologia y Obstetricia (The Spanish Society of Gynecology and Obstetrics)
This article is being co-published in the British Journal of Sports Medicine (Mottola MF, Davenport MH, Ruchat S-M, et al. Br J Sports Med 2018;52:1339–1346. https://doi.org/10.1136/bjsports-2018-100056). This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well-documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher.
Women have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to facilitate informed choice, women should be provided with information and support that is evidence based, culturally appropriate, and tailored to their needs. The values, beliefs, and individual needs of each woman and their family should be sought, and the final decision about the care and treatment options chosen by the woman should be respected.
Identification
Copyright
© 2018 Published by Elsevier Inc. on behalf of Society of Obstetricians and Gynaecologists of Canada.
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