JOINT SOGC/CSEP CLINICAL PRACTICE GUIDELINE
No. 367-2019 Canadian Guideline for Physical Activity throughout Pregnancy

https://doi.org/10.1016/j.jogc.2018.07.001Get rights and content

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).

  • 1

    All women without contraindication should be physically active throughout pregnancy (strong recommendation, moderate quality evidence). Specific subgroups were examined:

  • a

    Women who were previously inactive (strong recommendation, moderate quality evidence).

  • b

    Women diagnosed with gestational diabetes mellitus (weak recommendation,a low quality evidence).

  • c

    Women categorized as overweight or obese (pre-pregnancy body mass index ≥25 kg/m2) (strong recommendation,b low quality evidence).

  • 2

    Pregnant 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).

  • 3

    Physical activity should be accumulated over a minimum of 3 days per week; however, being active every day is encouraged (strong recommendation, moderate quality evidence).

  • 4

    Pregnant 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).

  • 5

    Pelvic 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).

  • 6

    Pregnant 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.

Section snippets

INTRODUCTION

Regular physical activity across the lifespan is associated with substantial health benefits including improvements in physical fitness and mental health, as well as decreased risk of chronic disease and mortality.1 Pregnancy is a unique period of a woman's life in which lifestyle behaviours, including physical activity, can significantly affect her health as well as that of her fetus.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 Although guidelines around the world recommend women without

METHODS

This 2019 Canadian Guideline for Physical Activity Throughout Pregnancy were developed according to the methodological strategy outlined in the AGREE II instrument.20 The goal of this guideline was to provide evidence-based recommendations regarding physical activity during pregnancy in the promotion of maternal, fetal, and neonatal health. The Guidelines Consensus Panel consisted of researchers in the field of prenatal exercise; methodological experts (AGREE II, GRADE; statistician, and

WHO SHOULD BE PHYSICALLY ACTIVE DURING PREGNANCY?

This guideline is intended for women who do not have contraindications (Table 2) that would prevent them from engaging in physical activity. Women with absolute contraindications may continue the usual activities of daily living but should not participate in more strenuous exercise. Women with relative contraindications should discuss the advantages and disadvantages of moderate-to-vigorous intensity physical activity with their obstetric care provider.

Recommendation

  • 1.

    All women without

WHAT PHYSICAL ACTIVITY IS RECOMMENDED DURING PREGNANCY?

Recommendations

  • 2.

    Pregnant women should accumulate at least 150 minutes of moderate-intensity physical activity each week to achieve clinically meaningful reductions in pregnancy complications (strong recommendation, moderate quality evidence).

  • 3.

    Physical activity should be accumulated over a minimum of 3 days per week; however, being active every day is encouraged (strong recommendation, moderate quality evidence).

  • 4.

    Pregnant women should incorporate a variety of aerobic exercise and resistance

CONSIDERATIONS FOR IMPLEMENTATION

The following guidance is based on the expert opinion of the Guidelines Consensus Panel.

HOW TO START BEING ACTIVE DURING PREGNANCY?

Previously inactive women are encouraged to start physical activity in pregnancy but may need to begin gradually, at lower intensity, and increase the duration and intensity as their pregnancy progresses. It is important to note that when dose-response relationships between physical activity and pregnancy outcomes were identified, more physical activity (frequency, intensity, duration, and volume) was associated with greater health benefits. However, an upper limit was not established.

It may be

RESOURCES FOR THE HEALTH CARE PROVIDER, EXERCISE PROFESSIONAL, AND PREGNANT WOMEN

The Physical Activity Readiness Medical Examination for Pregnancy (PARmed-X for Pregnancy) was developed by CSEP and endorsed by SOGC and Health Canada (and available in English, French and Spanish through CSEP's website: http://www.csep.ca/view.asp?ccid=517) as an aid for health care providers and exercise professionals to identify contraindications for pregnant women prior to their participation in physical activity.40

SUMMARY

The 2019 Canadian Guideline for Physical Activity Throughout Pregnancy represent a foundational shift in our view of prenatal physical activity from a recommended behaviour to improve quality of life to a specific prescription for physical activity to reduce pregnancy complications and optimize health across the lifespan of 2 generations. It is critical that these guidelines be implemented into clinical practice to achieve the significant and potentially lifelong health benefits for both mother

Funding Sources

This work is funded by a Knowledge Synthesis Grant from the Canadian Institutes of Health Research. Dr. Davenport is funded by an Advancing Women's Heart Health Initiative New Investigator Award supported by Health Canada and the Heart and Stroke Foundation of Canada.

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  • Cited by (95)

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    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.

    *Denotes joint first authorship

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