11/22/04njm

**Q**. Is exercise actually recommended in pregnancy? If so, why?

**A.** Yes, exercise is highly recommended in uncomplicated pregnancy.
It can help a lot.

There are many reasons to recommend exercise in pregnancy. Just two
reasons are:

Overweight and obese women have a significantly slower labor. (Vahratian
et al below) Pregravid obesity and diabetes independently increase the
risk for cesarean delivery. Given the disparate prevalence of obesity
and diabetes in the United States, body habitus has a significantly
larger impact on delivery risk. (Ehrenberg HM, et al below)

#### 

These are just two articles that report on the detrimental effects of
maternal obesity on the normal labor process. In Ehrenberg HM, et al.,
records for 12,303 deliveries showed pregravid obesity and diabetes
independently increase the risk for CD. Given the disparate prevalence
of obesity and diabetes in the United States, body habitus has a
significantly larger impact on CD risk.

Along with ACOG we should encourage strongly recommend exercise to our
pregnant patients, especially those with pregravid obesity and diabetes
in pregnancy. In the absence of medical or obstetrical complications,
pregnant women should be encouraged to continue and maintain an active
lifestyle during their pregnancies. Some modification in exercise
routines or activity patterns may be necessary because of maternal
physiological changes and fetal requirements.

Basically only moderate exercise is needed. As a rough rule of thumb,
just use the **"talk-sing test"** may be used -- the patient should be
able to talk while exercising; if she can sing, the pace can be
increased. Current guidelines for diabetes in pregnancy give an example
of a tested exercise program successfully used in AI/AN pregnant women.
See Appendix F, page 18 below

<http://www.ihs.gov/MedicalPrograms/MCH/w/documents/DMPreg102504_000.doc>

For optimal outcome, the Institute of Medicine advises a weight gain of

Underweight women (BMI\<19.8) 12.5 to 18 kg (28 to 40 lb)

Average weight (BMI 19.8 to 26.0) 11.5 to 16 kg (25 to 35 lb)

Overweight women
(BMI![](media/image1.png){width="8.333333333333333e-2in"
height="9.236111111111112e-2in"}26), 7 to 11.5 kg (15 to 25 lb)

These can be achieved with an additional 300 Kcal per day for average
weight women

**[Appendix F]{.underline}**

# [Exercise guidelines to improve glucose control]{.underline}

Type of activities:

Aerobic activities such as walking, stationary cycling, or swimming

Frequency:

At least 3 days per week

Duration:

20-45 minutes per session

Intensity:

Moderate. **The "talk-sing test"** may be used -- the patient should be
able to talk while

exercising; if she can sing, the pace can be increased. If using rating
of perceived

exertion (RPE) exertion level should feel "fairly light" to "somewhat
hard".

Patient should warm-up before and cool down after exercise, drink plenty
of water, and

have snacks nearby if needed.

Initial exercise consult:

> Assessment of current physical activities and level of readiness for
> exercise
>
> Education/Information on exercise and GDM
>
> Individualized exercise plan

Supervised exercise:

> Measure blood glucose pre and post exercise
>
> Exercise on treadmill and/or recumbent cycle
>
> Monitor perceived exertion
>
> Monitor blood pressure and/or heart rate as needed

<http://www.ihs.gov/MedicalPrograms/MCH/w/documents/DMPreg102504_000.doc>

**ACOG**

**Exercise During Pregnancy and the Postpartum Period Committee
Opinion** Number 267, January 2002

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11777528>

**UpToDate**

**Physiologic principles of exercise during pregnancy**

<http://www.uptodateonline.com/application/topic.asp?file=antenatl/12515>

**Recommendations for exercise during pregnancy and the postpartum
period**

<http://www.uptodateonline.com/application/topic.asp?file=antenatl/12055>

**Nutrition in pregnancy**

<http://www.uptodateonline.com/application/topic.asp?file=antenatl/6112>

**Overweight and obese women had a significantly slower labor**

Overweight and obese women had a significantly slower labor from 4 to 10
cm, compared with that of normal-weight women. The prevalence of
overweight and obesity is increasing among women of childbearing age,
yet few studies have explored in depth the effect of maternal overweight
and obesity on labor progression.

-Compared with normal-weight women, both overweight and obese women were
admitted earlier to labor and delivery, more frequently reported no or
irregular uterine contractions, more frequently had their labor induced,
and received oxytocin more often.

-Primary emergent cesarean delivery rates were higher for overweight and
obese women compared with normal-weight women. The majority of these
deliveries were performed during the first stage of labor because of an
indication of dystocia and fetal distress.

-Overweight and obese women had a significantly longer median duration
of labor from 4 to 10 cm compared with normal-weight women (7.5, 7.9,
and 6.2 hours, respectively), after adjusting for maternal height, net
weight gain, labor induction, membrane rupture, the timing and use of
epidural analgesia, oxytocin use, and fetal size.

-Compared with normal-weight women, the trend of a slower labor from 4
to 6 cm persisted in overweight women, and the trend of a slower labor
before 7 cm persisted in obese women.

-Given that nearly one half of women of childbearing age are either
overweight or obese, it is critical to consider differences in labor
progression by maternal prepregnancy BMI before additional interventions
are performed

Vahratian A, Zhang J, Troendle JF, et al. 2004. Maternal prepregnancy
overweight and obesity and the pattern of labor progression in term
nulliparous women. Obstetrics and Gynecology 104(5, Part 1):943-951.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15516383>

**Obesity and Diabetes Independently Increase Cesarean Delivery Risk**

CONCLUSION: Pregravid obesity and diabetes independently increase the
risk for CD. Given the disparate prevalence of obesity and diabetes in
the United States, body habitus has a significantly larger impact on CD
risk.

Ehrenberg HM, et al. The influence of obesity and diabetes on the risk
of cesarean delivery. Am J Obstet Gynecol. 2004 Sep;191(3):969-74.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15467574>