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Central Medical Journal of Obstetrics and Gynecology

Cite this article: Moyer C, May L (2014) Inuence of Exercise Mode on Maternal, Fetal, and Neonatal Health Outcomes. Med J Obstet Gynecol 2(2): 1036.

*Corresponding authors

Linda May, Department of Foundational Sciences

and Research, East Carolina University, USA, Tel: 252-

737-7072; Fax: 252-737-7049; E-mail:

Submitted:05 August 2014

Accepted: 21 August 2014

Published: 23 August 2014

ISSN: 2333-6439

Copyright

©2014 May et al.

OPEN ACCESS

Review Article

Inuence of Exercise Mode on

Maternal, Fetal, and Neonatal

Health OutcomesMoyer C1 and May L2*1 Department of Health and Human Sciences, Bridgewater College, USA2 Department of Foundational Sciences and Research, East Carolina University, USA

Keywords• Pregnancy

•Aerobic•Resistance

•Circuit

• Target heart rate

Abstract

Research has demonstrated aerobic exercise is safe and benecial for mother,

fetus, and neonate. Unlike aerobic exercise, little research has focused on the effects

of resistance training during pregnancy. Preliminary studies have shown that acute

resistance training is safe for pregnant women. It has been found to be effective in

increasing lean body mass in pregnant woman. Research studying chronic resistance

training during pregnancy has focused on delivery outcome rather than examining the

chronic health effects or adaptations of resistance training exposure for the expectant

mother. Additionally, scarce research has been done to examine the effects of acute

maternal resistance training on the fetus, except to conclude that the fetus is not at an

increased risk of distress during maternal resistance exercises.

Some researchers have studied circuit (aerobic and resistance) training on acute

maternal responses or chronic adaptations during pregnancy. In response to prolonged

circuit training during pregnancy, women who exercised more were less likely to have

a Cesarean delivery and spent less time recovering in the hospital. Furthermore,

research has not been completed on the fetal responses or adaptations as a result of

acute or chronic maternal circuit training throughout pregnancy, except to report that

birth weights are similar between exercising and control groups. Logically, if aerobic

and resistance exercise programs individually are safe for the pregnant woman and

her fetus, then a combination program would also be safe. Clearly, more research

is needed and this article will summarize our current state of knowledge regarding

exercise during pregnancy.

ABBREVIATIONS

ACSM: American College o Sports Medicine; ACOG:

American Congress o Obstetrics and Gynecology; SOGC: Society o

Obstetricians and Gynaecologists o Canada; CSEP: Canadian Societyor Exercise Physiology; HR: heart rate; HRV: heart rate variability;

HF: high requency power in requency domain o HRV; VO2:

oxygen consumption.

INTRODUCTION

Te purpose o this article is to compare the effects o aerobic,

resistance, and circuit training throughout pregnancy on maternal

and etal physiological adaptations. Te contents o this text will

expound on the available literature and its applicability to pregnant

patients. opics discussed include: guidelines or aerobic exercise

during pregnancy, maternal and etal responses to aerobic exercise,

offspring measures related to aerobic exercise, maternal and etal

responses to resistance training, and maternal and etal responses tocircuit training during pregnancy.

Guidelines for aerobic exercise

Te recommendations or aerobic exercise prescription during

pregnancy published by the ACSM, ACOG, SOGC, and CSEP ully

agree and cross-reerence one another. Tese recommendations begin

with clearance by a physician to participate in exercise. I a pregnant

woman is healthy and has a low-risk pregnancy (i.e. no contraindica-

tions or exercise as listed in (able 1), then she should participate in

moderate intensity aerobic exercise or at least 30 minutes most days

o the week, with a goal o 150 minutes per week [1-5]. Previously

sedentary, overweight and obese pregnant women are encouraged to

begin with 15 minutes per exercise bout and gradually increase to the

recommended 30 minutes [1-5]. Moderate intensity has been defined

as approximately 60-80% o maximum heart rate or target heart rate

zone (able 2), 12-14 on the Borg scale rating o perceived exertion

(able 3), or by using the “talk test,” which means being able to con-

verse while exercising without eeling short o breath [2,4-8]. Since

pregnancy involves numerous physiological and anatomical changes,

target heart rate (able 2) zones or non-gravid women are not suffi-cient to meet the physiological demands o the pregnancy. Due to this


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Med J Obstet Gynecol 2(2): 1036 (2014) 2/7

physiological phenomenon, target heart rate zones or normal weight,

overweight and obese pregnant women have been developed and are

listed in (able 2) [5,7,8]. Also, HR is the most accurate measure o

intensity, especially or women who have trained prior to pregnancy

[9]. Te goal o exercise during pregnancy is to maintain or increase

fitness and avoid maximal exertion [5, 10,11]. o achieve this goal, itis currently recommended to utilize aerobic types o exercise such as

walking, cycling, and swimming [1-3, 5,12]. Pregnant women should

avoid activities that increase their risk o losing balance or could re-

sult in etal trauma, such as ball-sports and recreational activities like

skiing, biking outside, horseback riding, etc.[1-3,5,12]. Overall, these

recommendations are similar to those or non-gravid populations as

published by the ACSM [3]. Previously sedentary, overweight and

obese non-gravid individuals should exercise at a light to moderate

intensity (57-75% HR max

), 20-30 minutes a day, most days o the week

[3].

Maternal responses to aerobic exercise

Aerobic exercise during pregnancy provides as many health

benefits as in non-pregnant populations [13-15]. Benefits range rom

improvements in cardiovascular unctioning, metabolic unctioning,

weight management, and mental health unctions acutely and afer

prolonged periods o exercise training. Tough gravid women

experience similar benefits to exercise as the adult population, their

acute responses to exercise are slightly different when compared to

pre-pregnancy values because o the physiological and anatomical

changes associated with pregnancy (able 3)[3]. As in non-pregnant

populations, pregnant women o all BMI classifications experience

adaptations, such as improvements in resting heart rate (HR)

and cardiac output (Q), in response to chronic aerobic exercise

[12,16,17]. Blood pressure (BP) does not significantly change

throughout the course o pregnancy between women who exercise

throughout pregnancy and those who do not, regardless o the level

o intensity [16,18]. Santos et al ound that aerobic submaximal

capacity is improved in overweight pregnant women afer an aerobic

exercise training program. Te regulation o insulin, glucose, and

blood lipids is also improved in pregnant women who participate in

aerobic exercise [4,12,16], as in non-gravid populations [14]. Body

composition measures also change, such as decreased at deposition,

in response to aerobic exercise during pregnancy similar to the non-

pregnant population [12-16]. Gestational weight gain is much more

variable or overweight and obese pregnant women participating in

an exercise program [15, 17, 19]. In addition, previously sedentary

women who begin an exercise program during pregnancy experiencedimproved cardiovascular unction, improved body composition,

and less weight gain during pregnancy, thus decreasing their risk o

developing gestational diabetes mellitus and hypertension [7].

Ruchat et al. [20] utilized a light intensity and moderate intensity

aerobic exercise program coupled with a nutrition intervention in

normal weight pregnant women. Although participants gained excess

pregnancy weight prior to the start o this intervention, women in the

exercise groups gained significantly less weight throughout the entire

course o their pregnancy than women in the control group. Despite

this finding in the exercising groups, neonate weight, length, and BMI

did not significantly differ between groups [20]. Mottola et al. [21]

employed a similar exercise and nutrition intervention in overweight

and obese pregnant women. No significant differences were ound or

total weight gained between the groups [21]. Te amount o weight

Absolute Contraindications to

Aerobic Exercise DuringPregnancy

Relative Contraindications to

Aerobic Exercise DuringPregnancy

Hemodynamically signiicant

heart diseaseSevere anemia

Restrictive lung diseaseUnevaluated maternal cardiac

arrhythmia

Incompetent cervix/cerclage Chronic bronchitis

Multiple gestation at risk for

premature laborPoorly controlled type I diabetes

Persistent second or third

trimester bleedingExtreme morbid obesity

Placenta previa after 26 weeks

gestation

Extreme underweight (body mass

index 40 years old 125-140

Table 2: Modiied target heart rate zones developed for normal,

overweight, and obese pregnant women.

Borg Scale for Rating of Perceived Exertion (RPE)

6

7 Very, very light 8

9 Very light

10

11 Fairly light

12

13 Somewhat hard

14

15 Hard

16

17 Very hard

18

19 Very, very hard

20

Table 3: Borg RPE Scale. Adapted from Borg GA. Psychophysical bases of

perceived exertion. Med Sci Sport Ex . 1982; 14: 377-81.


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gained over the course o the pregnancy was within the acceptable

range and not in excess, according to guidelines published by a

Canadian health initiative. Weight gain o the intervention groups

was not compared to matched normal-weight controls.

Management o gestational weight gain is important in preventingthe development o gestational diabetes mellitus and hypertension

in pregnancy, preventing delivery complications and adverse etal

outcomes, and decreasing the amount o weight retained post-partum

[4, 20-23]. Rossner [24] ound that weight gain during pregnancy was

the most significant predictor o weight retention 1 year postpartum.

Weight retention can have adverse effects or the woman, increasing

her susceptibility to various disease states, as well as adverse etal

health outcomes in uture pregnancies. Edwards et al. [25] reported

that excess gestational weight gain may have greater consequences or

neonatal health than maternal health in normal weight, overweight

and obese pregnant women. Oken et al. [23] urther supported this

claim, finding that excess gestational weight gain related directly

to inant and childhood weight statuses. Tey ound that excessgestational weight gain resulted in increased child adiposity at age 3

in normal weight, overweight and obese pregnant women [23]. Tus,

the management o weight gained during pregnancy is important to

improving maternal, neonatal, and childhood health and well-being.

Tese improvements in maternal health during pregnancy

contribute to overall improved health post-partum, decreased risk o

adverse conditions, and improved outcomes in uture pregnancies.

Aerobic exercise positively influences pregnancy outcome by

decreasing complications or both mother and baby during labor and

delivery, including a decreased need or Cesarean section delivery

and decreased hospitalization time or maternal recovery [26-28].

Since pregnant women respond and adapt to exercise in a similarmanner, the ensuing health benefits are likely to be similar regardless

o weight classification and parity.

Fetal responses to aerobic exercise

Previous research has shown etal adaptations in response

to maternal aerobic exercise [29-33]. Szymanski and Satin [33]

monitored etal HR beore, during, and afer single moderate and

vigorous intensity exercise sessions. Fetal HR increased post-exercise

in both groups, but did not exceed normal limits [33]. Ultrasound was

also used to monitor the etus beore and afer exercise sessions with

no adverse outcomes noted. Tese results indicate that acute maternal

aerobic exercise o moderate or vigorous intensity is tolerated by

the etus. Other studies have also reported no signs o etal distressin response to acute maternal aerobic exercise. Kennelly et al. [34]

measured etal HR and variability beore and afer a single maternal

aerobic exercise test in overweight pregnant women. No significant

change in etal HR occurred during the exercise test [34]. However, a

significant difference in HRV was noted between pre and post exercise

measures. Tese results suggest that a single bout o high intensity

maternal aerobic exercise does not increase the risk o etal distress.

Clapp et al. [35, 36] measured amniotic erythropoietin levels to

determine i regular maternal aerobic exercise throughout pregnancy

induces a etal hypoxic effect. Results indicated that erythropoietin

levels were not significantly different between exercising women

and non-exercising controls, urther suggesting that the etus is not

in danger o chronic hypoxia or bradycardia as a result o chronic

maternal aerobic exercise [35,36].

Multiple studies [29-31,37-40] have ound that measures o etal

HRV increase with gestational age. Multiple studies have ound

that offspring o exercising pregnant women do not significantly

differ in birth size (i.e. length, abdominal circumerence) compared

to offspring o women who do not exercise throughout pregnancy.

wo studies completed by Clapp [41] and Clapp et al.[42] reportedthat, at birth, neonates o exercising mothers weighed less due to less

body at percentage and total body at mass than neonates o controls

[41, 42]. However, there was no significant difference ound in lean

body mass between the offspring o each group [41, 42]. Szymanski

and Satin [33] ound that birth weight was not significantly different

between neonates o exercising pregnant women and controls.

Ruchat et al. [20] ound that offspring o normal weight pregnant

women who participated in an exercise and nutrition intervention

did not significantly differ in regards to birth weight and BMI among

maternal intervention groups (light intensity, moderate intensity,

and control). A similar study employing overweight and obese

pregnant women also ound that birth weight o offspring did not

differ significantly between overweight and obese pregnant women

or between exercising women and matched controls rom a local

medical database [21]. Each o these studies provides evidence that

etuses o exercising pregnant women, o any weight classification,

are likely to have a normalized birth weight.

Maternal responses to resistance training

Studies have demonstrated that participation in resistance

training during pregnancy is sae (56), and women elt better about

themselves, gained less weight, and elt relie rom somatic problems

(i.e. nausea, atigue, headache) [43]. As pregnancy progressed, the

intensity o exercise decreased [43]. Further studies ound resistance

with aerobic exercise is associated with decreased prevalence o

hypertension and diabetes during pregnancy relative to aerobic only

or controls [44]. Resistance exercise during pregnancy also decreases

patients with GDM that need insulin and improves glycemic control

[45, 46]. Studies show no adverse pregnancy outcomes associated with

resistance training during pregnancy [47]. Women may experience

increased strength and flexibility rom participating in resistance

exercise while pregnant [47]. O’Connor et al. [11] employed a 12

week, low-to-moderate intensity resistance training program in 32

pregnant women. Te purpose o the study was to determine the

saety and efficacy o a strength program to decrease low back pain

and to determine the rate o musculoskeletal injury due to resistance

training during pregnancy. Te program consisted o six different

exercises ocusing on legs, arms, back, and abdomen. Intensity wasmaintained by using the 6-20 Borg scale o perceived exertion, which

was also applied to help progress the external load o each exercise

completed. Te average external load increased progressively over

the 12 week period, which suggests an increase in maternal strength

over time, although no assessments were completed to substantiate

this claim. No injuries were reported over the 12 week program,

but the primary symptom reported was dizziness [11]. Tere was

also no significant change in maternal resting BP noted rom the

beginning to the end o the 12 week program [11]. O’Connor et al.

[11] emphasized and recommended education o proper breathing

and lifing techniques and general muscular conditioning throughout

the 12 week program.

Resistance training is a mode o exercise employed by many

individuals to maintain or increase muscle strength and has grown


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in popularity among many different populations. However, in the

pregnant population, only a ew studies have analyzed the acute and

chronic effects o resistance training on the mother and etus [7, 10-

12, 48]. Preliminary studies have shown that acute resistance training

can be sae and efficacious or the mother and her unborn child

[7, 10, 11, 48]. Avery et al. [48] measured maternal HR and BP inresponse to strength exercises during the third trimester. During each

session (at 31, 32, and 33 weeks gestation), participants completed

hand grip, single leg extension, and double leg extension exercises in

seated and supine positions with varying intensity levels. Maternal

HR and BP were measured with each increase in intensity or both

positions o the aorementioned exercises. Te measured responses

to strength training in pregnant women were similar to those o non-

pregnant controls, with no differences in BP at rest and during each

exercise [48]. BP in both groups was greatest when larger muscle

groups were utilized, while HR was only elevated in pregnant women

[48]. O’Connor et al. [11] also reported no significant difference in

maternal BP beore and afer acute maternal resistance training o 6

different strength exercises. Tis unaltered measurement o BP beoreand afer acute resistance exercise during pregnancy is the same as

noted in response to acute aerobic exercise [16, 49].

A case study completed in a single obese pregnant woman

investigated the use o progressive resistance training throughout the

2nd and 3rd trimesters [50]. Te participant completed a combination

o upper and lower body exercises three times a week. Te pregnant

mother maintained a moderate intensity, regulated by her heart rate.

Over the course o the program, the participant gained lean body

mass, decreased BMI, and increased training volume by 58% [50].

It appears rom these results that moderate intensity progressive

resistance training throughout pregnancy is sae and beneficial to

maternal health. Similarly, Barakat et al. [51] reported no significantdifference in maternal gestational weight gain or type o delivery in

normal weight pregnant women in response to chronic light intensity

resistance training. No adverse health outcomes or injuries were

reported during the training period.

Tese responses in the pregnant population are similar to those

reported in non-gravid populations [52, 53]. Dionne et al. [52]

reported increased at ree mass and resting energy expenditure

in normal weight non-pregnant women afer a 6 month resistance

training program. Donges and Duffield [53] reported increased

at ree mass and decreased at mass in overweight non-pregnant

women afer 10 weeks o either resistance training or aerobic

training programs. Tereore, because gravid and non-gravid women

experience similar responses and adaptations to aerobic exercise, it

can be surmised that they will have similar responses and adaptations

as a result o acute and chronic resistance exercises and training.

Tese results are due to the average external load increased

progressively over the 12-week period, which suggests an increase in

maternal strength over time, although no assessments were completed

to substantiate this claim. Similarly, Barakat et al. [51] reported no

significant difference in maternal gestational weight gain or type o

delivery in normal weight pregnant women in response to chronic

light intensity resistance training. No adverse health outcomes or

injuries were reported during the training period.

Abdominal (“core”) training is important resistance exercise that

helps keep abdominal muscles strong (or delivery), but a study ound

prenatal or postnatal abdominal exercises helps reduce diastasis

recti [54]. Tese responses in the pregnant population are similar

to those reported in non-gravid populations [52, 53]. Dionne et al.

[52] reported increased at ree mass and resting energy expenditure

in normal weight non-pregnant women afer a 6 month resistance

training program. Donges and Duffield [53] reported increased

at ree mass and decreased at mass in overweight non-pregnant

women afer 10 weeks o either resistance training or aerobic training

programs. Regardless o whether a woman participates in aerobic

only, aerobic + resistance training, or control group, there are no

differences in preterm labor, mode o delivery, and gestational age

[44].

Fetal responses to resistance training

In the aorementioned study by Avery et al. [48], etal HR

was measured beore, during, and afer each maternal resistance

exercise, with no significant changes in etal HR observed. Tis study

concluded that the etus tolerates acute maternal strength exercise

well and that acute maternal strength exercises do not cause etaldistress beore, during, or afer. Tis agrees with a retrospective

study that ound requency, intensity, and time measures related

to resistance training were inversely related to etal complications,

such that increased resistance training was associated with decreased

likelihood o etal complication during pregnancy [55]. However,

the primary recommendation o this study is or pregnant women

to avoid supine exercises in the third trimester as it may increase

the risk o etal hypoxia and bradycardia due to increased maternal

BP and decreased blood flow to the etus [48]. Barakat et al. [51]

reported increased etal HR in response to light intensity maternal

resistance exercises. Tis response indicates that the acute etal HR

response to maternal resistance exercises is normal and similar to the

response reported when exposed to acute maternal aerobic exercise.Tese results urther substantiate the claim that the etus is not at an

increased risk o distress or adverse health outcomes in response to

acute maternal exercise, regardless o the type and intensity.

Although many studies have reported no negative or adverse

pregnancy outcomes as a result o maternal resistance training [11,

56, 57], none o these studies have completed measures o etal

health in response to chronic maternal resistance training. Tereore,

very little is known about the long term effects o chronic maternal

resistance training on etal and neonatal health, even though it

appears to be sae. Post-hoc analyses (unpublished data) show that

intermittent maternal exercises (i.e. strength training) correlates with

increased overall HRV, whereas continuous maternal exercise (i.e.aerobic) correlates with increased HF (a parasympathetic measure).

Tese analyses suggest that different modes o maternal exercise

have different effects on the developing cardiovascular system.

Additionally, there is no research regarding the influence o acute

or chronic maternal resistance training in overweight and obese

pregnant women. Although the subjects participating in Dr. May’s

previous study represent all weight classifications, the study was not

specifically designed to look at the effects o overweight and obese

pregnant mothers’ exercise on etal heart outcomes. Tere are also

no generally accepted guidelines or recommendations or resistance

training during pregnancy to accompany those or aerobic exercise.

Unortunately, the present literature is lacking in this area while there

is a growing interest in providing research-based resistance training

recommendations to pregnant populations.


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Maternal responses to circuit training

Te combination o aerobic and resistance training has become

more popular among healthy, non-gravid populations. Aerobic

training is known to increase cardiovascular and pulmonary health

while resistance training results in increased muscular strength andendurance. Research on the acute responses and chronic adaptations

in maternal and etal health o combining these modes o exercise

has not been sufficiently addressed in the pregnant population.

Acute responses o maternal health due to participation in circuit

training during gestation have not been reported. However, non-

gravid participants in a single session o circuit training experienced

decreased systolic and diastolic BP, stroke volume, and cardiac

output and increased systemic vascular resistance and HR compared

to control values, acute aerobic training only, and acute resistance

training only [58].

Few studies have measured maternal chronic adaptations and

maternal health outcomes in response to circuit training during

pregnancy. A study by Hall and Kaumann [26] explored pregnancy

outcomes afer a combination training exercise regimen throughout

pregnancy. Tis regimen consisted o a 3-5 minute warm-up, ollowed

by individually prescribed strength and flexibility exercises, and

ended with a 1-2 mile cycling workout. Exercise groups were divided

into low, medium, and high according to the number o exercise

sessions completed throughout the course o pregnancy. Women who

completed more exercise sessions were less likely to have a Cesarean

section than women who exercised less or not at all (Med/Hi > Low/

Control). Additionally, women who exercised spent less time in the

hospital afer delivery compared to non-exercise controls. Price et

al. [28] measured cardiorespiratory fitness, strength, and flexibility

in overweight pregnant women participating in a circuit trainingprogram throughout the 2nd and 3rd trimesters. At each testing session

(every 6 weeks rom 12 wks GA to 8 wks postpartum), the exercising

groups had higher cardiorespiratory fitness, measured by power

produced during a 2 mile walk, than controls, with a significant

difference at 30-32 weeks gestational age [28]. Exercising pregnant

women had significantly higher strength, measured by a 7kg lif test,

than controls rom 18 weeks gestational age to 8 weeks postpartum

[28]. Flexibility measures were not significantly different between

groups. Significantly ewer women in the exercise group delivered

via Cesarean section than controls and time to recovery postpartum

was significantly shorter as well [28].Circuit training combining

aerobic and resistance exercise leads to adaptive benefits o the

placenta [59]. Tis adaptation o the vascular system reduces the risko pre-eclampsia, diabetes, and hypertension while pregnant [59]. It

is suggested that HR is more accurate or gauging exercise intensity

during weight-bearing exercise while pregnant [9].

Fetal responses to circuit training

Very ew studies have researched the effects o maternal circuit

training on etal health. A retrospective analysis ound that overall

women decrease their level o aerobic and resistance exercise during

pregnancy, and most importantly maternal and etal complications

occur at a rate similar to the general population [55]. Hall and

Kauffman [26] ound no significant differences in birth weight o

offspring among groups. However, a significant difference was ound

in 1 and 5-minute APGAR scores o offspring among groups, withthose o women who completed the most exercise sessions having a

higher score. Price et al. [28]. also reported no significant differences

in birth weight between exercise and control groups. Although little

has been reported as ar as acute or chronic etal health measures in

response to maternal circuit training, based on the available data this

type o exercise is also sae during pregnancy.

Since other studies have shown that pregnant populations have

similar acute and chronic aerobic and resistance exercise training

responses as non-gravid populations, one can postulate that pregnant

populations will also benefit rom the use o combination training

regimens similar to their non-gravid counterparts. Although

preliminary studies have shown that resistance training and aerobic

training do not adversely affect etal development individually, the

effects on etal health outcomes rom combining these two modes o

exercise warrants urther investigation, especially in overweight and

obesemothers.

DISCUSSION AND CONCLUSION

Various types o exercise throughout pregnancy have beenproven sae and efficacious or the mother and her unborn child.

Although a popular belie remains that women who are not

previously active should rerain rom beginning regular exercise

during pregnancy, a plethora o research has reuted this claim.

Moderate intensity aerobic exercise is sae and recommended or

improved maternal and etal health outcomes such as cardiovascular

health, management o gestational weight gain, prevention o chronic

diseases, neonatal morphometric, and childhood health measures.

Resistance and circuit training has grown in popularity among non-

gravid populations, but currently remains inadequately researched

regarding pregnancy. More research is needed to determine i these

modes o exercise provide any long-term benefit to maternal, etal,

and/or neonatal health. Additionally, little research has ocused onoverweight and obese pregnant women who, like their non-gravid

counterparts, appear to significantly benefit rom participation in a

regular moderate intensity exercise program throughout gestation.

Studies are currently being done to address many o these unanswered

questions related to maternal and etal health and exercise during

pregnancy.

ACKNOWLEDGEMENTS

We would like to thank East Carolina University or their internal

unds to support the continued work in the area o exercise and

pregnancy.

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Exercício, Mãe, Feto ( Revisão )